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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View Related questions
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.
Correct Answer is D
Explanation
Choice A rationale
Trouble sleeping is not directly relevant to the administration of pyridostigmine, which is used to improve muscle strength in myasthenia gravis.
Choice B rationale
Unexplained weight loss is not a primary concern when administering pyridostigmine. The focus should be on the patient’s ability to swallow and recent oral intake.
Choice C rationale
Difficulty with urination is not a primary concern for pyridostigmine administration. The medication’s effects on muscle strength and swallowing are more critical.
Choice D rationale
Recent oral intake is crucial to assess because pyridostigmine can cause gastrointestinal side effects, and food intake can affect its absorption and effectiveness.