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. 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.

A. Sodium. B. Hemoglobin. C. Glucose. D. Total protein.

Correct Answer is B

Explanation

A. Sodium levels are important for fluid balance but are not directly related to the symptoms of fatigue and pallor in this context.
B. Hemoglobin is crucial to assess in this situation because the client’s fatigue and pallor may indicate anemia, which could be a side effect of long-term diclofenac use and is common in clients with rheumatoid arthritis.
C. Glucose levels are essential for metabolic health but are not relevant to the client's current symptoms.
D. Total protein levels can provide information on nutritional status and liver function, but they are not the most immediate concern given the client's presentation.

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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

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Explanation

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Correct Answer is B

Explanation

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