The client is a 27-year-old male who had an exploratory laparotomy 8 days ago following a gunshot wound to the abdomen. The surgeons evacuated a large amount of blood in the peritoneum and repaired a liver laceration. The client was in the intensive care unit (ICU) for 4 days and in the surgical floor for 4 days. He started a regular diet 3 days ago but is now refusing to eat and has had several episodes of vomiting in the past 3 hours. Which action should the nurse take?

Choice A reason: Unexplained weight loss is not directly relevant to pyridostigmine administration. Myasthenia gravis affects neuromuscular junctions, and pyridostigmine enhances acetylcholine, improving muscle strength. Weight loss may indicate systemic issues, but it does not affect the drug’s immediate safety or efficacy, making this choice secondary.

Choice B reason: Trouble sleeping is unrelated to pyridostigmine’s administration. The drug targets acetylcholinesterase, increasing muscle strength in myasthenia gravis, but does not typically affect sleep. Insomnia may reflect other conditions, but it is not a critical pre-administration concern compared to cholinergic side effects.

Choice C reason: Difficulty with urination is critical, as pyridostigmine’s cholinergic effects can exacerbate urinary retention by stimulating bladder smooth muscle. In myasthenia gravis, this may worsen existing autonomic dysfunction, risking complications like infection, making this the most important information to assess before administration.

Choice D reason: Recent oral intake is relevant for gastrointestinal side effects, as pyridostigmine may cause nausea, but it is less critical than urinary issues. Taking the drug with food can mitigate nausea, but urinary retention poses a greater immediate risk, making this choice secondary.

Choice A reason: Administering an antiemetic addresses vomiting but is not the first priority. Confusion and projectile vomiting in MS suggest increased intracranial pressure or brain injury post-fall, requiring neurological assessment to identify life-threatening conditions like hematoma, which takes precedence over symptom management.

Choice B reason: A head-to-toe neurological assessment is critical first, as confusion and projectile vomiting post-fall in MS indicate potential traumatic brain injury or exacerbation. Assessing pupil response, motor function, and consciousness level identifies neurological deterioration, guiding urgent interventions to prevent further brain damage.

Choice C reason: Determining the last corticosteroid dose is relevant for MS management but not urgent. Confusion and vomiting suggest acute neurological injury, requiring immediate assessment. Steroid history may guide long-term care but is secondary to evaluating current neurological status post-fall.

Choice D reason: Determining the neurological baseline is useful but not the first action. Acute confusion and vomiting require immediate assessment to detect changes like brain injury. Baseline data provide context but delay critical evaluation of current neurological status, making this choice less urgent.