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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Related Questions
Correct Answer is D
Explanation
D A stool softener can help prevent straining during bowel movements, which could increase intraocular pressure and potentially harm the surgical site. Additionally, the nurse should advise the client to avoid activities that could increase pressure in the eye, such as bending at the waist, lifting heavy objects, or engaging in strenuous activities for a certain period post-surgery.
A Monitoring for changes in pupillary sizes is not specific to this type of surgery.
B Turn, cough, and deep breathe every 2 hours: This instruction is more relevant for clients who have undergone surgery or are at risk of developing respiratory complications, such as pneumonia. It is not specifically related to cataract extraction with a lens implant.
C Clients are usually advised to sleep with the head elevated or to avoid lying on the operative side to minimize the risk of intraocular pressure changes and discomfort.
Correct Answer is C
Explanation
C. Hemoglobin is a protein in red blood cells that carries oxygen throughout the body. Anemia, characterized by low hemoglobin levels, can lead to symptoms such as fatigue, weakness, and pale appearance. Diclofenac, like other nonsteroidal anti-inflammatory drugs (NSAIDs), can cause gastrointestinal bleeding, which may result in iron deficiency anemia.
A. While abnormality in sodium levels can occur and may contribute to symptoms such as fatigue, pale appearance, and weakness, sodium levels are not typically affected directly by diclofenac use or rheumatoid arthritis.
B. Low total protein levels can contribute to symptoms such as fatigue and weakness. However, total protein levels may not be directly affected by diclofenac use or rheumatoid arthritis.
D. Assessing glucose levels is not be the most relevant laboratory value to review in this situation.
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