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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Promoting effective swallowing is relevant for dysphagia but not the primary goal for sliding hiatal hernia, where the stomach protrudes into the thorax, causing reflux. Preventing acid reflux into the esophagus is critical to reduce irritation and complications like esophagitis, making swallowing secondary.

Choice B reason: Preventing esophageal reflux is the primary goal for sliding hiatal hernia, as the stomach’s protrusion through the diaphragm allows gastric acid to reflux, causing heartburn and esophageal damage. Nursing actions like elevating the head of the bed and avoiding trigger foods minimize reflux, protecting the esophagus.

Choice C reason: Maintaining intact oral mucosa is unrelated to hiatal hernia, which affects the gastroesophageal junction. Reflux causes esophageal, not oral, irritation. The focus is on preventing acid reflux to protect the esophagus, making oral mucosa maintenance irrelevant to the condition’s pathophysiology.

Choice D reason: Increasing intestinal peristalsis is not a goal for hiatal hernia, which involves gastroesophageal reflux, not intestinal motility. Enhanced peristalsis may worsen reflux by increasing intra-abdominal pressure. Preventing reflux is prioritized to manage symptoms and prevent esophageal complications.

A. Apply warm compresses to affected joints B. Restrict all physical activity C. Administer high-dose corticosteroids D. Encourage high-sodium diet

Correct Answer is A

Explanation

Choice A reason: Warm compresses reduce morning stiffness in rheumatoid arthritis by increasing blood flow and relaxing muscles around inflamed joints. This alleviates synovial inflammation, improving mobility and comfort, making it a key nonpharmacologic intervention to manage early daily symptoms effectively.

Choice B reason: Restricting physical activity worsens stiffness and joint deformity in rheumatoid arthritis. Warm compresses are prioritized, as they directly reduce synovial inflammation and improve mobility, enabling gentle exercise, making complete activity restriction counterproductive to joint health and function.

Choice C reason: High-dose corticosteroids are reserved for severe rheumatoid arthritis flares, not routine morning stiffness. Warm compresses are safer, reducing stiffness through localized heat, improving joint function without systemic side effects, making them the priority intervention for daily symptom management.

Choice D reason: A high-sodium diet increases fluid retention, potentially worsening joint inflammation in rheumatoid arthritis. Warm compresses directly alleviate morning stiffness by enhancing circulation, making them the priority, as dietary sodium does not address acute joint symptoms effectively.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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