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 D

Explanation

Choice A reason: Obtaining an arterial blood gas assesses oxygenation and acid-base status, useful in COPD management, but is not required before postural drainage. This invasive procedure is unnecessary for routine drainage, which mobilizes secretions. Explaining positions prepares the client, enhancing cooperation and effectiveness.

Choice B reason: Performing drainage after meals risks aspiration or vomiting, as a full stomach increases intra-abdominal pressure in COPD patients. Postural drainage is most effective when performed on an empty stomach, making this approach incorrect. Patient education on positioning is the priority.

Choice C reason: Shallow, fast breathing is counterproductive in COPD, as it reduces tidal volume and worsens hypercapnia. Postural drainage requires slow, deep breaths to mobilize secretions and improve ventilation. Explaining positions ensures proper technique, making this breathing instruction incorrect.

Choice D reason: Explaining that the client may be placed in five positions (e.g., prone, supine, lateral) prepares them for postural drainage, which uses gravity to mobilize lung secretions in COPD. This education enhances compliance and effectiveness, as proper positioning is critical for therapeutic success, making it the correct approach.

A. Assist with mobility and fall prevention B. Encourage high-protein meals C. Restrict fluid intake D. Promote social isolation

Correct Answer is A

Explanation

Choice A reason: Assisting with mobility and fall prevention is critical in Parkinson’s disease, as bradykinesia and rigidity increase fall risk. Physical therapy and assistive devices enhance safety, reducing injury risk, making this the priority intervention to maintain functional independence and prevent fractures.

Choice B reason: High-protein meals may interfere with levodopa absorption in Parkinson’s, worsening symptoms. Mobility assistance is the priority, as falls are a leading cause of injury, requiring immediate intervention to ensure safety, making dietary protein secondary to physical support.

Choice C reason: Restricting fluid intake is inappropriate, as hydration prevents constipation in Parkinson’s. Mobility and fall prevention are critical, as motor symptoms increase injury risk. Assisting with mobility addresses the primary functional challenge, making fluid restriction irrelevant to priority care.

Choice D reason: Promoting social isolation worsens depression in Parkinson’s, a common comorbidity. Mobility assistance is the priority, as falls due to motor impairment are a significant risk, requiring immediate intervention to ensure safety, making social isolation counterproductive to care.

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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

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