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 the client's last dose of corticosteroids.

Determine neurological baseline prior to the fall.

Administer a PRN IV antiemetic as prescribed.

Complete head-to-toe neurological assessment.

Answer and Explanation

The Correct Answer is D

A. Determine the client's last dose of corticosteroids: This may be helpful later in understanding the client's MS management, but it is not the immediate priority in an acute neurological situation.
B. Determine neurological baseline prior to the fall: While important for comparison, establishing the client’s current status through assessment takes priority.
C. Administer a PRN IV antiemetic as prescribed: Vomiting may be a sign of increased intracranial pressure (ICP); treating the symptom without assessing for underlying neurological compromise could delay recognition of a critical condition.
D. Complete head-to-toe neurological assessment: This is the priority. The client’s confusion and projectile vomiting may indicate a traumatic brain injury with increased ICP. Immediate neurological assessment is necessary to identify life-threatening changes and guide urgent interventions.

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Correct Answer is D

Explanation

A. Type II hypersensitivity typically involves antibody-mediated destruction of cells and is not consistent with the symptoms described.
B. An autoimmune response involves the immune system attacking the body's own tissues and is not applicable in this scenario.
C. Cell-mediated hypersensitivity involves T cells and does not typically present with immediate systemic symptoms such as shortness of breath following a bee sting.
D. An IgE response hypersensitivity is an immediate hypersensitivity reaction, which aligns with the symptoms of rash, shortness of breath, and hypotension observed after the bee sting.

A. Over-enunciate word syllables. B. Exaggerate nonverbal expressions. C. Decrease speaking speed. D. Raise voice volume to a shout.

Correct Answer is C

Explanation

A. Over-enunciating word syllables can be perceived as patronizing and may not improve understanding for clients with hearing difficulties.
B. Exaggerating nonverbal expressions can help convey meaning, but it does not address the immediate need for clear verbal communication.
C. Decreasing speaking speed allows the client more time to process what is being said, which is particularly important for older adults who may need additional time to understand spoken words.
D. Raising voice volume to a shout may not be necessary and could distort the clarity of speech, making it harder for the client to understand.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

An older female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the nurse to "speak up" so that she can hear the questions. Which action is best for the nurse to take?

Correct Answer is C

Explanation

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