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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Pancreatitis is often associated with elevated serum amylase levels due to pancreatic inflammation. Therefore, this combination of clinical symptoms and laboratory findings is valuable in assessing the severity and confirming the diagnosis of pancreatitis.
A. While these are important clinical findings, they are not specific to pancreatitis and may not provide definitive information about the severity or cause of the condition.
C. Chronic constipation and serum gastrin levels are not typically associated with pancreatitis.
D. Serum Helicobacter pylori (H. pylori) antibody results and urine output amounts are not directly related to pancreatitis. H. pylori infection is associated with peptic ulcers and gastritis but not typically with pancreatitis.
Correct Answer is ["B","C","E"]
Explanation
B. Start the client on antibiotic therapy - Antibiotics are typically prescribed to treat bacterial pneumonia, which is a common cause of pneumonia.
C. STAT complete blood count (CBC), basic metabolic panel (BMP), and blood cultures - These tests help in assessing the severity of the infection, evaluating electrolyte balance, and identifying the causative organism respectively.
E. Send sputum for culture & sensitivity - This helps in identifying the specific organism causing the pneumonia and determining the most effective antibiotic for treatment.
A. At an oxygen saturation above 90%, the client does not necessarily require oxygen supplementation
D. A ventilation/ perfusion scan is needed in cases of suspected pulmonary embolism which is unlikely in this case.
F. Another chest X ray is not important as a recent one is present. No much changes is expected in the period of the few hours.
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