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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While working as a construction worker may involve exposure to various pathogens, it is not as critical as the client's history of substance use.
B. A reported history of alcoholism is significant because terbinafine is metabolized by the liver, and a history of alcohol use could affect liver function, increasing the risk of liver toxicity. This finding requires further assessment before administration.
C. Thick and yellow toenails indicate a fungal infection, which is the reason for the terbinafine prescription but does not impact the immediate safety of administering the medication.
D. A white blood cell count of 8,500/mm³ is within the normal range and does not indicate an immediate concern related to medication administration.
Correct Answer is C
Explanation
A. Observing body language and movement can provide clues about the client's pain but does not directly assess the quality of the pain experienced.
B. Identifying effective pain relief measures is important for managing pain but does not assess the quality of pain itself.
C. Asking the client to describe the pain directly assesses its quality, allowing the nurse to understand its characteristics, such as intensity, duration, and type (e.g., sharp, dull, throbbing).
D. Providing a numeric pain scale is useful for quantifying pain intensity but does not capture the qualitative aspects of the pain experience.
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