A nurse is caring for a client who has a concussion and reports nausea and vomiting. Which of the following actions should the nurse take first?
Administer antiemetic medication as prescribed
Assess the client's level of consciousness and orientation
Provide oral fluids and crackers to the client
Notify the provider of the client's condition
The Correct Answer is B
Choice A reason:
This is an incorrect answer. Administering antiemetic medication as prescribed is an appropriate action for the nurse to take, but not the first one. The nurse should first assess the client's neurological status, as nausea and vomiting can be signs of increased intracranial pressure (ICP) or worsening brain injury.
Choice B reason:
This is a correct answer. Assessing the client's level of consciousness and orientation is the first action that the nurse should take when caring for a client who has a concussion and reports nausea and vomiting. The nurse should use tools such as the Glasgow Coma Scale (GCS) or the Alert, Verbal, Painful, Unresponsive (AVPU) scale to evaluate the client's neurological function and identify any changes or deterioration.
Choice C reason:
This is an incorrect answer. Providing oral fluids and crackers to the client is not an appropriate action for the nurse to take, especially not the first one. The nurse should avoid giving anything by mouth to the client who has nausea and vomiting, as this can increase the risk of aspiration or dehydration.
Choice D reason:
This is an incorrect answer. Notifying the provider of the client's condition is an important action for the nurse to take, but not the first one. The nurse should first assess the client's neurological status and gather relevant data before reporting to the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Choice A reason:
This is a correct answer. Wearing appropriate protective equipment such as helmets and mouth guards helps to reduce the risk and severity of concussion by absorbing some of the impact force and protecting the head and teeth from injury.
Choice B reason:
This is a correct answer. Reporting any symptoms of concussion to the coach or trainer immediately helps to ensure proper diagnosis and treatment of concussion by a health care provider. Symptoms may include headache, dizziness, nausea, vomiting, confusion, memory loss, blurred vision, or sensitivity to light or noise.
Choice C reason:
This is an incorrect answer. Seeking medical attention if symptoms persist for more than 24 hours is not enough for concussion management. The nurse should advise the athletes to seek medical attention as soon as possible after a suspected concussion, regardless of how long the symptoms last or how severe they are.
Choice D reason:
This is a correct answer. Taking a baseline cognitive test before the season starts helps to establish a reference point for comparison after a concussion. A cognitive test measures mental functions such as memory, attention, reaction time, and problem-solving.
Choice E reason:
This is a correct answer. Drinking plenty of fluids and eating a balanced diet after a concussion helps to promote healing and recovery by providing hydration and nutrition to the brain and body.
Correct Answer is B
Explanation
Choice A reason:
This is an incorrect answer. The nurse should not instruct the client to return to work or school as soon as possible after a concussion. The client should rest and avoid cognitive tasks that require concentration, attention, or memory until their symptoms resolve and they are cleared by their provider.
Choice B reason:
This is a correct answer. The nurse should instruct the client to avoid driving or operating machinery until cleared by the provider after a concussion. Driving or operating machinery can be dangerous and impairing for the client who may have symptoms such as headache, dizziness, fatigue, blurred vision, or slowed reaction time.
Choice C reason:
This is an incorrect answer. The nurse should not instruct the client to resume sports or physical activities within a week after a concussion. The client should avoid strenuous or risky activities that could cause another concussion or worsen their symptoms until they are asymptomatic and cleared by their provider.
Choice D reason:
This is an incorrect answer. The nurse should not instruct the client to take ibuprofen or aspirin for pain relief after a concussion. Ibuprofen and aspirin are nonsteroidal anti-inflammatory drugs (NSAIDs) that can increase the risk of bleeding in the brain or interfere with blood clotting.
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