A client with multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

Determine the client's last dose of corticosteroids.

Determine neurological baseline prior to the fall.

Administer a PRN IV antiemetic as prescribed.

Complete head-to-toe neurological assessment.

Answer and Explanation

The Correct Answer is D

A. Determine the client's last dose of corticosteroids: This may be helpful later in understanding the client's MS management, but it is not the immediate priority in an acute neurological situation.
B. Determine neurological baseline prior to the fall: While important for comparison, establishing the client’s current status through assessment takes priority.
C. Administer a PRN IV antiemetic as prescribed: Vomiting may be a sign of increased intracranial pressure (ICP); treating the symptom without assessing for underlying neurological compromise could delay recognition of a critical condition.
D. Complete head-to-toe neurological assessment: This is the priority. The client’s confusion and projectile vomiting may indicate a traumatic brain injury with increased ICP. Immediate neurological assessment is necessary to identify life-threatening changes and guide urgent interventions.

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Correct Answer is B

Explanation

A. While the nurse can perform oral care, it is essential for the UAP to assist where appropriate, and oral care should not be solely left for the nurse.
B. A soft-bristled toothbrush is the best option for the client with painful mouth ulcers, as it is gentle and reduces the risk of further irritation.
C. Offering mouthwash may not be appropriate, especially if it contains alcohol, as it could further irritate the ulcers; additionally, thorough cleansing is typically more effective with careful brushing rather than rinsing alone.
D. Wearing sterile gloves is unnecessary for oral care; standard precautions, including clean gloves, should be used, but sterile gloves are not required for this type of care.

A. Fried rice. B. Potatoes. C. Corn chips. D. Oatmeal.

Correct Answer is D

Explanation

A. Fried rice is typically made with rice, which is gluten-free, so this option would generally be safe for a client with celiac disease unless it contains gluten-containing soy sauce.
B. Potatoes are naturally gluten-free and can be safely included in a gluten-free diet.
C. Corn chips can also be gluten-free, but it’s important to check the label for potential cross-contamination.
D. Oatmeal can often contain gluten due to cross-contamination during processing unless it is specifically labeled as gluten-free, indicating that further teaching is needed for the client regarding safe food choices.

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A client with multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

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