An adult client with multiple sclerosis (MS) fell while walking to the bathroom. On transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?
Determine client's last dose of corticosteroids.
Administer a PRN IV antiemetic as prescribed.
Determine neurological baseline prior to the fall.
Complete head-to-toe neurological assessment.
The Correct Answer is D
D. The priority nursing intervention should be to assess and stabilize the patient's immediate medical needs. The confusion and vomiting could be indicative of increased intracranial pressure or another acute condition requiring immediate attention. Therefore, the most appropriate first action would be to complete a head-to-toe neurological assessment.
A. Determining the last dose of corticosteroids may not address the immediate concerns of confusion and projectile vomiting.
B. Administering an antiemetic is not the priority action as the vomiting is likely due to head trauma with subsequent raised ICP.
C. Understanding the baseline neurological status is essential for subsequent assessment and management but it may not address the immediate concerns of confusion and vomiting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Hydromorphone is an opioid analgesic that can cause constipation as a side effect by slowing down gastrointestinal motility. Prolonged use of opioids, such as hydromorphone, increases the risk of developing opioid-induced constipation (OIC), which can lead to discomfort, bowel obstruction, and other complications if left untreated.
B. Edema is not typically associated with hydromorphone use, especially when administered for a short duration.
C. Hydromorphone administration is not typically associated with significant alterations in heart rate or rhythm, especially when administered at appropriate doses.
D. hydromorphone administration is not typically associated with alterations in blood glucose levels. Therefore, assessing capillary glucose levels may not be the most relevant assessment in this scenario.
Correct Answer is A
Explanation
A. A hydrocolloidal gel dressing can be beneficial as it maintains moisture and supports autolytic debridement. This type of dressing also helps in protecting the wound from external contaminants and can be left in place for several days, depending on the level of exudate.
B. Replacing the gauze with a transparent dressing, which is typically used for minimal to moderate exudating wounds, could dry out the wound or those that are not designed for significant granulation tissue
C. Leaving the dressing off is not advisable as it exposes the wound to potential infection and delays healing.
D. Increasing the frequency of dressing changes is not specified as a standard treatment and could potentially disrupt the healing process.
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