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

Determine client's last dose of corticosteroids.

Administer a PRN IV antiemetic as prescribed.

Determine neurological baseline prior to the fall.

Complete head-to-toe neurological assessment.

Answer and Explanation

The Correct Answer is D

D. The priority nursing intervention should be to assess and stabilize the patient's immediate medical needs. The confusion and vomiting could be indicative of increased intracranial pressure or another acute condition requiring immediate attention. Therefore, the most appropriate first action would be to complete a head-to-toe neurological assessment.

A. Determining the last dose of corticosteroids may not address the immediate concerns of confusion and projectile vomiting.

B. Administering an antiemetic is not the priority action as the vomiting is likely due to head trauma with subsequent raised ICP.

C. Understanding the baseline neurological status is essential for subsequent assessment and management but it may not address the immediate concerns of confusion and vomiting.

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Correct Answer is D

Explanation

D. Since the client has reported only minimal reduction in symptoms after taking lansoprazole (a proton pump inhibitor used to treat GERD) for one full week, it suggests that the current dosage may not be sufficient for adequate symptom relief. Therefore, the nurse should notify the healthcare provider.

A. Auscultating the client's bowel sounds and measure the abdominal girth. This action is not directly related to the client's reported lack of symptom improvement with lansoprazole.

B. Lansoprazole is typically taken before meals to maximize its effectiveness in reducing gastric acid production.

C.While it is true that healing of erosive esophagitis may take several weeks with treatment, the client's report of minimal symptom reduction suggests that further evaluation and potentially a change in treatment approach are warranted.

A. Until the excess pressure is reduced. B. Until a smaller angle can be restored. B. For long-term control of normal eye pressure. C. For long-term control of pain and swelling. D. For long-term control of pain and swelling.

Correct Answer is B

Explanation

C. In open-angle glaucoma, the goal of treatment is to achieve and maintain normal intraocular pressure (IOP) to prevent further damage to the optic nerve and preserve vision. Eye drops are typically prescribed as a long-term therapy to control IOP and prevent progression of the disease.

A. While reducing intraocular pressure (IOP) is indeed a primary goal of glaucoma treatment, the use of eye drops for glaucoma is typically long-term to maintain normal eye pressure, not just until the excess pressure is reduced.

B. Eye drops are prescribed for long-term use to maintain normal IOP and prevent further damage to the optic nerve.

C. Open-angle glaucoma is typically painless, and swelling is not a common symptom.

D. Glaucoma is not primarily associated with pain and swelling; rather, it is characterized by increased intraocular pressure and damage to the optic nerve, which can lead to vision loss if left untreated.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is newly diagnosed with erosive esophagitis secondary to gastroesophageal reflux disease (GERD) reports to the home health nurse that there has been only a minimal reduction in symptoms after taking lansoprazole PO for one full week. Which action should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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