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?
Determine neurological baseline prior to the fall.
Determine client’s last dose of corticosteroids.
Administer a PRN IV antiemetic as prescribed.
Complete head to toe neurological assessment.
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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Correct Answer is B
Explanation
Choice A rationale
Teaching anxiety reduction methods for feelings of suffocation is important but not the most immediate action needed to address the client’s respiratory symptoms.
Choice B rationale
Increasing the daily intake of oral fluids to liquefy secretions is the most important action for the nurse to instruct the client about self-care. This helps to thin the mucus, making it easier to expectorate and improving breathing.
Choice C rationale
Calling the clinic if undesirable side effects of medications occur is important but not the most immediate action needed to address the client’s respiratory symptoms.
Choice D rationale
Avoiding crowded enclosed areas to reduce pathogen exposure is important but not the most immediate action needed to address the client’s respiratory symptoms.
Correct Answer is B
Explanation
Choice A rationale
Providing step-by-step verbal directions may not be effective for clients with Huntington’s disease due to their cognitive impairments, which can include forgetfulness, impaired judgment, and difficulty concentrating.
Choice B rationale
Escorting the client to the cafeteria is the best approach as it ensures the client reaches the destination safely. Clients with Huntington’s disease often have unsteady gait and involuntary movements, making it difficult for them to navigate independently.
Choice C rationale
Orienting the client to the color-coding system may not be effective due to the cognitive impairments associated with Huntington’s disease, such as difficulty concentrating and impaired judgment.
Choice D rationale
Using the hospital map to show the client where the cafeteria is located is not practical for clients with Huntington’s disease due to their cognitive impairments, which can include forgetfulness and difficulty concentrating.