The nurse is caring for a client who fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is provided with a history of vomiting twice. Which intervention should the nurse implement first?

Complete head-to-toe neurological assessment

Determine client’s last dose of corticosteroids

Determine neurological baseline prior to the fall

Administer a PRN antiemetic as prescribed

Answer and Explanation

The Correct Answer is A

Choice A reason: A head-to-toe neurological assessment is the priority after a fall with vomiting, as it evaluates for traumatic brain injury or increased intracranial pressure. Vomiting may indicate neurological compromise. This assessment guides urgent interventions, as undetected brain injury can lead to rapid deterioration in the ICU.

Choice B reason: Determining the last corticosteroid dose is relevant for managing underlying conditions but not the immediate priority post-fall. Vomiting and potential head injury require neurological assessment first, as brain trauma poses an acute risk, whereas corticosteroid timing is secondary to stabilizing neurological status.

Choice C reason: Determining the neurological baseline before the fall is useful for comparison but not the first action. A current neurological assessment identifies acute changes or injuries post-fall, as vomiting may signal brain injury, making immediate evaluation critical to guide treatment in the ICU.

Choice D reason: Administering a PRN antiemetic controls vomiting, improving comfort, but does not address the underlying cause. Vomiting post-fall may indicate neurological injury, requiring immediate assessment. Neurological evaluation takes precedence to rule out brain trauma before symptomatic treatment with antiemetics.

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Correct Answer is B

Explanation

Choice A reason: HIV does not primarily cause a deficiency in antibody production. B-cells produce antibodies, but HIV targets CD4 T-cells, impairing their ability to activate B-cells. This indirectly reduces antibody effectiveness, but the primary mechanism is T-cell destruction, not a direct antibody production deficit, making this incorrect.

Choice B reason: HIV infects and destroys helper T-cells (CD4 cells), critical for coordinating immune responses. By reducing CD4 cell counts, HIV impairs activation of B-cells and cytotoxic T-cells, leading to immune suppression. This is the primary mechanism of AIDS-related immune deficiency, making it the correct explanation for HIV pathology.

Choice C reason: Proliferation of suppressor T-cells (regulatory T-cells) is not a primary HIV mechanism. HIV depletes CD4 cells, not suppressor T-cells, which modulate immune responses. While immune dysregulation occurs, the hallmark is CD4 destruction, not suppressor T-cell proliferation, making this an inaccurate description of HIV’s action.

Choice D reason: HIV does not increase B-lymphocyte numbers. It impairs B-cell function indirectly by destroying CD4 cells, which are needed to activate B-cells for antibody production. B-cell hyperactivity may occur in early HIV, but the primary immune suppression results from CD4 cell loss, not B-cell proliferation.

A. Administer an antacid as prescribed B. Assess the characteristics of the pain C. Check for recent NSAID use D. Obtain a stool sample for occult blood

Correct Answer is B

Explanation

Choice A reason: Administering an antacid relieves epigastric pain but is premature without assessing pain characteristics. Pain in peptic ulcer disease may indicate complications like perforation, requiring urgent evaluation. Assessment guides whether antacids or other interventions are appropriate, prioritizing patient safety.

Choice B reason: Assessing pain characteristics (e.g., location, intensity, radiation) is the first step, as epigastric pain in peptic ulcer disease may signal complications like bleeding or perforation. This data guides interventions, ensuring timely management of potentially life-threatening conditions, making it the priority action.

Choice C reason: Checking NSAID use identifies ulcer triggers but is secondary to pain assessment. Pain characteristics determine urgency, as severe or radiating pain may indicate perforation, requiring immediate action. Assessment provides critical data before investigating contributing factors like medication history.

Choice D reason: Obtaining a stool sample for occult blood detects gastrointestinal bleeding but is not the first step. Assessing pain characteristics identifies urgent complications like perforation, guiding whether diagnostic tests or interventions are needed, making pain assessment the initial priority.

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The nurse is caring for a client who fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is provided with a history of vomiting twice. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client with a history of peptic ulcer disease reports epigastric pain. Which action should the nurse take first?

Correct Answer is B

Explanation

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