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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

C. Hemoglobin is a protein in red blood cells that carries oxygen throughout the body. Anemia, characterized by low hemoglobin levels, can lead to symptoms such as fatigue, weakness, and pale appearance. Diclofenac, like other nonsteroidal anti-inflammatory drugs (NSAIDs), can cause gastrointestinal bleeding, which may result in iron deficiency anemia.

A. While abnormality in sodium levels can occur and may contribute to symptoms such as fatigue, pale appearance, and weakness, sodium levels are not typically affected directly by diclofenac use or rheumatoid arthritis.

B. Low total protein levels can contribute to symptoms such as fatigue and weakness. However, total protein levels may not be directly affected by diclofenac use or rheumatoid arthritis.

D. Assessing glucose levels is not be the most relevant laboratory value to review in this situation.

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}

Explanation

Tachypnea refers to abnormally rapid breathing, characterized by an increased respiratory rate. In adults, tachypnea is typically defined as a respiratory rate above 20 breaths per minute at rest.

Tachycardia is a medical condition characterized by a rapid heart rate, typically above 100 beats per minute in adults at rest.

Eupnea refers to normal, unlabored breathing at a normal rate and depth. It is characterized by regular inhalations and exhalations without any signs of respiratory distress or abnormalities.

Hypothermia is a medical condition characterized by an abnormally low body temperature, typically below 95°F (35°C).

Bradycardia is a medical condition characterized by an abnormally slow heart rate, typically below 60 beats per minute in adults.

Hyperthermia is a medical condition characterized by an abnormally high body temperature, typically above 100.4°F (38°C).

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who is taking diclofenac for rheumatoid arthritis. During a clinic visit, the client appears pale and reports increasing fatigue. Which of the client's serum laboratory values is most important for the nurse to review?

Correct Answer is C

Explanation

Patient Data Exhibits According to the client's vital signs, he is experiencing dropdown and dropdown

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}

Explanation

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