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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 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.

Correct Answer is C

Explanation

Choice A rationale

Offering mouthwash for thorough cleansing after brushing teeth can be too harsh for clients with painful mouth ulcers caused by Candida albicans. It may cause further irritation and discomfort.

Choice B rationale

While assistive personnel can help with personal care, oral care should not be left solely to the nurse. Providing appropriate tools and guidance for the client to perform oral care is essential.

Choice C rationale

Providing a soft-bristled toothbrush is appropriate for clients with oral Candida albicans. It helps in gentle cleaning without causing additional pain or damage to the mucosa.

Choice D rationale

Wearing sterile gloves is not necessary for routine oral care. Clean gloves are sufficient unless there is a specific need for sterility, such as in surgical procedures.

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