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 A
Explanation
Choice A rationale
Acute pancreatitis is a potential complication after cholecystectomy. The persistent upper abdominal pain radiating to the back is a classic symptom of acute pancreatitis. This condition can occur due to the migration of gallstones or other factors affecting the pancreas.
Choice B rationale
Biliary duct obstruction can cause upper abdominal pain, but it is less likely to present with pain radiating to the back. This condition typically presents with jaundice and other symptoms.
Choice C rationale
Surgical site infection can cause abdominal pain, but it is usually localized to the surgical site and does not typically radiate to the back. Other signs of infection, such as fever and redness, would also be present.
Choice D rationale
Hepatorenal failure is a severe condition that can occur in patients with liver disease, but it is not commonly associated with pain radiating to the back. It typically presents with symptoms of liver and kidney dysfunction.
Correct Answer is A
Explanation
Choice A rationale
Reported history of alcoholism is the most important assessment finding to address before administering terbinafine HCL. Terbinafine is metabolized by the liver, and clients with a history of alcoholism may have impaired liver function, increasing the risk of hepatotoxicity. Monitoring liver function and assessing for signs of liver damage are crucial before starting treatment.
Choice B rationale
Toenails appear thick and yellow is a common symptom of fungal toenail infection, but it is not the most critical assessment finding to address before administering terbinafine HCL. The focus should be on assessing liver function.
Choice C rationale
Employed as a construction worker is not the most critical assessment finding to address before administering terbinafine HCL. While occupational exposure to fungi may be relevant, the primary concern is liver function.
Choice D rationale
White blood cell count of 8,500/mm³ (8.5 x 10⁹/L) is within the normal range and is not the most critical assessment finding to address before administering terbinafine HCL. The primary concern is liver function.