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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Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Palpating for joint warmth and swelling is the best technique for early rheumatoid arthritis, as it detects synovitis, a hallmark of the disease. Inflamed joints are warm, swollen, and tender due to autoimmune-driven synovial proliferation, enabling early identification and intervention to prevent joint damage.

Choice B reason: Measuring range of motion assesses joint function but is less specific for early rheumatoid arthritis. Reduced motion occurs later, after significant synovial inflammation or damage. Palpating for warmth and swelling directly identifies active synovitis, making it more effective for early detection.

Choice C reason: Assessing grip strength evaluates muscle and joint function but is nonspecific for early rheumatoid arthritis. Weakness may result from pain or later joint damage. Palpating for warmth and swelling targets synovial inflammation, the earliest sign, making it the preferred technique for early diagnosis.

Choice D reason: Observing gait and posture detects functional limitations but is not specific for early rheumatoid arthritis. Gait changes occur with advanced disease or other conditions. Palpating for joint warmth and swelling directly identifies synovial inflammation, the primary early feature, making it more diagnostic.

A. Provide a numeric pain scale B. Observe body language and movement C. Ask the client to describe the pain D. Identify effective pain relief measures

Correct Answer is C

Explanation

Choice A reason: A numeric pain scale quantifies pain intensity but not its quality, such as burning or stabbing. Descriptive data provide a fuller picture of pain characteristics, which guide treatment. Numbers alone lack the detail needed to assess the nature of the pain experience.

Choice B reason: Observing body language and movement, like grimacing or guarding, indicates pain presence but not its specific quality. Subjective descriptions from the client reveal characteristics like sharpness or throbbing, which are critical for diagnosis and management, making observation secondary to verbal reports.

Choice C reason: Asking the client to describe the pain captures its quality, including type, location, and pattern (e.g., burning, stabbing). This subjective data is essential for diagnosing the pain’s cause and tailoring treatment, as it provides detailed insights beyond intensity or observable signs, making it the best approach.

Choice D reason: Identifying effective pain relief measures is part of pain management, not assessment of pain quality. Understanding the pain’s characteristics through description is necessary before selecting interventions. This approach is premature without first gathering detailed subjective data from the client.

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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

Which technique should the nurse use when assessing for early signs of rheumatoid arthritis?

Correct Answer is A

Explanation

To assess the quality of an adult client’s pain, which approach should the nurse use?

Correct Answer is C

Explanation

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