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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 D

Explanation

Choice A rationale

Observing pupil response of the right eye is not relevant to the care of the left eye post-cataract extraction.

Choice B rationale

Sleeping flat in a supine position is not recommended as it can increase intraocular pressure. Elevating the head is advised.

Choice C rationale

Turning, coughing, and deep breathing every 2 hours is not specific to cataract surgery and can increase intraocular pressure.

Choice D rationale

Administering a stool softener is important to prevent straining during bowel movements, which can increase intraocular pressure and affect healing.

Correct Answer is D

Explanation

Choice A rationale

Total protein levels are not directly related to the symptoms of pallor and fatigue. While important, they do not provide immediate insight into the client’s current condition.

Choice B rationale

Sodium levels are crucial for overall health but are not directly related to the symptoms of pallor and fatigue. Monitoring sodium is important for fluid balance but not for diagnosing anemia.

Choice C rationale

Glucose levels are essential for managing diabetes and other metabolic conditions but are not directly related to the symptoms of pallor and fatigue. Monitoring glucose is important for overall health but not for diagnosing anemia.

Choice D rationale

Hemoglobin levels are directly related to the symptoms of pallor and fatigue. Diclofenac, an NSAID, can cause gastrointestinal bleeding, leading to anemia. Therefore, reviewing hemoglobin levels is crucial in this scenario.

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