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A client with multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

A.

Determine neurological baseline prior to the fall.

B.

Determine client’s last dose of corticosteroids.

C.

Administer a PRN IV antiemetic as prescribed.

D.

Complete head to toe neurological assessment.

Answer and Explanation

The Correct Answer is D

Choice A rationale

 

Determining the neurological baseline prior to the fall is important but not the immediate priority. The client’s current confusion and projectile vomiting suggest a potential acute condition that needs immediate assessment.

 

Choice B rationale

 

Determining the client’s last dose of corticosteroids is relevant for managing multiple sclerosis but does not address the immediate concern of confusion and vomiting.

 

Choice C rationale

 

Administering a PRN IV antiemetic as prescribed can help manage vomiting but does not address the underlying cause of the symptoms.

 

Choice D rationale

 

Completing a head-to-toe neurological assessment is the priority intervention. The client’s confusion and projectile vomiting could indicate increased intracranial pressure or another acute neurological condition that requires immediate attention.

 


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View Related questions

Correct Answer is A

Explanation

Choice A rationale

The severity of nausea and vomiting and serum amylase results are crucial in diagnosing and managing pancreatitis. Elevated serum amylase levels are a key indicator of pancreatitis, and the severity of nausea and vomiting can help assess the patient’s condition and response to treatment.

Choice B rationale

Reports of chronic constipation and serum gastrin levels are not directly related to the acute management of pancreatitis. Chronic constipation is more associated with gastrointestinal motility disorders, and serum gastrin levels are typically measured in conditions like Zollinger-Ellison syndrome.

Choice C rationale

Serum Helicobacter pylori (H. pylori) antibody results and urine output amounts are not directly relevant to the acute management of pancreatitis. H. pylori is associated with peptic ulcer disease, and urine output is more relevant in assessing renal function.

Choice D rationale

The presence of bowel sounds and the degree of abdominal pain are important but not as specific as serum amylase levels in diagnosing pancreatitis. Bowel sounds can be affected by various conditions, and abdominal pain is a common symptom in many gastrointestinal disorders.

Correct Answer is C

Explanation

Choice A rationale

Lansoprazole, a proton pump inhibitor (PPI), typically requires several weeks to achieve its full therapeutic effect. Notifying the healthcare provider for a dosage change after only one week is premature and not supported by clinical guidelines.

Choice B rationale

Auscultating bowel sounds and measuring abdominal girth are not directly related to the effectiveness of lansoprazole in treating GERD. These actions are more relevant for assessing gastrointestinal motility and potential complications like bowel obstruction.

Choice C rationale

Healing of erosive esophagitis with PPIs like lansoprazole usually takes several weeks. Advising the client that healing typically takes several weeks to occur is appropriate and aligns with the expected therapeutic timeline.

Choice D rationale

Lansoprazole should be taken before meals, not after, to maximize its effectiveness. Confirming that the client is taking the medication one hour after meals would not address the issue of symptom persistence.

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