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
Autoimmune response is not the correct type of immune reaction for a bee sting. Autoimmune responses involve the body’s immune system attacking its own tissues, which is not the case with bee stings.
Choice B rationale
IgE response hypersensitivity is the correct type of immune reaction for a bee sting. Bee stings can trigger an IgE-mediated hypersensitivity reaction, leading to symptoms such as rash, difficulty breathing, and low blood pressure. This type of reaction is also known as anaphylaxis.
Choice C rationale
Cell-mediated hypersensitivity is not the correct type of immune reaction for a bee sting. Cell-mediated hypersensitivity involves T cells and is typically associated with conditions like contact dermatitis, not bee stings.
Choice D rationale
Type II hypersensitivity is not the correct type of immune reaction for a bee sting. Type II hypersensitivity involves antibody-mediated destruction of cells, which is not the case with bee stings.
Correct Answer is A
Explanation
Choice A rationale
Hematemesis, or vomiting blood, is a critical sign of bleeding esophageal varices, which can be life-threatening. Clients with chronic cirrhosis and esophageal varices are at high risk for variceal bleeding due to increased portal hypertension. Monitoring for hematemesis is essential to provide timely intervention and prevent complications.
Choice B rationale
Anorexia, or loss of appetite, is a common symptom in clients with chronic liver disease, but it is not the most critical problem to monitor in clients with esophageal varices. The primary concern is the risk of variceal bleeding.
Choice C rationale
Clay-colored stool indicates a lack of bile in the stool, which can occur in liver disease. However, it is not the most critical problem to monitor in clients with esophageal varices. The primary concern is the risk of variceal bleeding.
Choice D rationale
Brown, foamy urine can be a sign of liver dysfunction, but it is not the most critical problem to monitor in clients with esophageal varices. The primary concern is the risk of variceal bleeding.