The nurse is caring for a client who fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is provided with a history of vomiting twice. Which intervention should the nurse implement first?
Complete head-to-toe neurological assessment
Determine client’s last dose of corticosteroids
Determine neurological baseline prior to the fall
Administer a PRN antiemetic as prescribed
The Correct Answer is A
Choice A reason: A head-to-toe neurological assessment is the priority after a fall with vomiting, as it evaluates for traumatic brain injury or increased intracranial pressure. Vomiting may indicate neurological compromise. This assessment guides urgent interventions, as undetected brain injury can lead to rapid deterioration in the ICU.
Choice B reason: Determining the last corticosteroid dose is relevant for managing underlying conditions but not the immediate priority post-fall. Vomiting and potential head injury require neurological assessment first, as brain trauma poses an acute risk, whereas corticosteroid timing is secondary to stabilizing neurological status.
Choice C reason: Determining the neurological baseline before the fall is useful for comparison but not the first action. A current neurological assessment identifies acute changes or injuries post-fall, as vomiting may signal brain injury, making immediate evaluation critical to guide treatment in the ICU.
Choice D reason: Administering a PRN antiemetic controls vomiting, improving comfort, but does not address the underlying cause. Vomiting post-fall may indicate neurological injury, requiring immediate assessment. Neurological evaluation takes precedence to rule out brain trauma before symptomatic treatment with antiemetics.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Solar radiation delivers approximately 99.97% of Earth's climate system energy. The sun emits electromagnetic waves, primarily in visible and infrared spectra, absorbed by Earth's surface and atmosphere. This energy fuels atmospheric circulation, ocean currents, and the hydrological cycle, establishing temperature gradients that drive global weather and climate patterns. Sunspot cycles cause minor variations but affirm solar dominance.
Choice B reason: Geothermal heat, from radioactive decay in Earth's core and mantle plus residual formation heat, contributes only about 0.025% to the climate energy budget. It powers volcanic activity and tectonic processes, with localized effects like geothermal springs, but its role in atmospheric or oceanic circulation is negligible compared to solar radiation’s extensive influence.
Choice C reason: Tidal forces, driven by gravitational interactions between Earth, the moon, and the sun, produce oceanic tides, contributing less than 0.001% to the climate system’s energy. Tides influence coastal mixing but lack the magnitude to drive atmospheric circulation or global climate, making them insignificant compared to solar radiation’s vast energy input.
Choice D reason: Human activities, such as fossil fuel burning and deforestation, release greenhouse gases, altering climate by trapping solar heat. These are secondary effects, not primary energy sources, with negligible direct energy contribution. They modify solar radiation absorption, acting as feedback mechanisms, not independent drivers like the sun’s direct energy.
Correct Answer is A
Explanation
Choice A reason: Hyperthyroidism increases metabolic rate, causing tachycardia and potential arrhythmias due to elevated thyroid hormone levels stimulating cardiac beta-receptors. Monitoring heart rate and rhythm is critical to detect cardiovascular complications, guiding urgent treatment to prevent heart failure or atrial fibrillation.
Choice B reason: High-calorie snacks address weight loss in hyperthyroidism but are secondary to cardiovascular risks. Tachycardia and arrhythmias pose immediate threats, making heart rate monitoring the priority, as uncontrolled hyperthyroidism can lead to life-threatening cardiac events before nutritional needs are addressed.
Choice C reason: Supplemental oxygen is not routinely needed in hyperthyroidism unless respiratory distress occurs, which is rare. Elevated heart rate and arrhythmias are more immediate concerns, as hyperthyroidism’s cardiac effects are primary, making heart monitoring critical to prevent acute cardiovascular complications.
Choice D reason: Restricting fluid intake is inappropriate, as hyperthyroidism increases metabolism, risking dehydration. Heart rate monitoring is prioritized, as tachycardia and arrhythmias are direct, life-threatening effects of excess thyroid hormone, requiring immediate assessment to guide antithyroid therapy and prevent cardiac crises.
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