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 C
Explanation
Choice A rationale
Potatoes are naturally gluten-free and safe for individuals with celiac disease.
Choice B rationale
Corn chips are also naturally gluten-free and safe for individuals with celiac disease.
Choice C rationale
Oatmeal can be contaminated with gluten during processing, making it unsafe for individuals with celiac disease unless it is certified gluten-free.
Choice D rationale
Fried rice is typically gluten-free, but it is essential to ensure that no gluten-containing ingredients or cross-contamination occurs during preparation.
Correct Answer is D
Explanation
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.