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 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.