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 C

Explanation

A. While teaching about eye drops is important, it is not the immediate priority following eye surgery.
B. Obtaining vital signs is essential for overall recovery but is not the most immediate concern related to the eye surgery.
C. Providing an eye shield to be worn while sleeping is crucial to protect the eye after surgery, preventing accidental injury or pressure on the surgical site.
D. Encouraging deep breathing and coughing exercises is important for overall recovery but is not specific to eye surgery and does not address the immediate need for eye protection.

A. Hemoccult test on sputum collected from hemoptysis. B. Positive purified protein derivative (PPD) skin test. C. Sputum culture positive for Mycobacterium tuberculosis. D. Chest x-ray or computed tomography (CT).

Correct Answer is C

Explanation

A. A hemoccult test on sputum is used to detect blood and is not specific to TB.
B. A positive PPD skin test indicates exposure to TB but does not confirm active disease; further testing is required.
C. A sputum culture positive for Mycobacterium tuberculosis is the definitive test for confirming active tuberculosis, as it isolates the organism.
D. A chest x-ray or CT can suggest the presence of TB but does not provide a definitive diagnosis; culture is necessary for confirmation.

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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?

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