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 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.

A. Reduction in number of liquid stools B. Improved mental status C. Ability to ambulate independently D. Increase in urine output

Correct Answer is B

Explanation

Choice A reason: Lactulose increases stool frequency and liquidity to excrete ammonia in hepatic encephalopathy. A reduction in liquid stools would indicate reduced effectiveness, as the medication’s cathartic effect is essential for ammonia removal. This is not the expected therapeutic response, as increased bowel movements are desired.

Choice B reason: Lactulose reduces blood ammonia levels in hepatic encephalopathy by promoting its excretion in stool, improving mental status. Ammonia accumulation causes neurological symptoms like confusion. Improved cognition and alertness are the primary therapeutic goals, making this the expected response to effective lactulose therapy.

Choice C reason: Ambulation ability is unrelated to lactulose’s mechanism in hepatic encephalopathy. While improved mental status may indirectly aid mobility, lactulose directly targets ammonia reduction, not physical function. This is not the primary therapeutic response, as the medication addresses neurological, not musculoskeletal, symptoms in this condition.

Choice D reason: Lactulose does not directly affect urine output, as it acts in the gastrointestinal tract to excrete ammonia. While hydration status may influence urine, the medication’s primary effect is on bowel movements and ammonia reduction, not renal function, making this an incorrect therapeutic expectation.

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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

The nurse is caring for a client with a new diagnosis of hyperthyroidism. Which intervention should the nurse prioritize?

Correct Answer is A

Explanation

A client has been administered lactulose for several days. Which therapeutic response should the nurse expect for a client with hepatic encephalopathy?

Correct Answer is B

Explanation

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