Nokea
An adult female with multiple sclerosis (MS) falls while walking to the bathroom. On transfer to the intensive care unit, she is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?
- A. Determine client's last dose of corticosteroids
- B. Determine neurological baseline prior to the fall
- C. Administer a PRN IV antiemetic as prescribed
- D. Complete head to toe neurological assessment.
Correct Answer: D
Rationale: The symptoms suggest increased intracranial pressure or a neurological emergency. A thorough neurological assessment is necessary to identify the cause and guide further interventions.
You may also like to solve these questions
What are THREE long-term complications that can occur after repair of coarctation of the aorta in an infant?
- A. Berry aneurysms
- B. Persistent systemic hypertension
- C. Re-coarctation
- D. All of the above
Correct Answer: D
Rationale: Long-term follow-up is necessary for patients who have undergone repair of coarctation due to risks of recurrence or complications.
After a transurethral resection of the prostate (TURP), a client has bloody urine output with large clots. The nurse implements the postoperative prescription to irrigate the indwelling catheter PRN to maintain the catheter's patency. Which action should the nurse implement?
- A. Clamp the catheter for 30 minutes prior to irrigating with saline
- B. Manually irrigate the catheter with sterile saline as prescribed
- C. Increase the client's oral fluid intake to flush out clots naturally
- D. Remove the catheter and notify the healthcare provider immediately
Correct Answer: A
Rationale: Clamping the catheter before irrigation prevents sudden fluid shifts and ensures that irrigation is performed effectively.
Which clinical manifestation should the nurse expect to see as shock progresses in a child and becomes decompensated shock?
- A. Thirst
- B. Irritability
- C. Apprehension
- D. Confusion and somnolence
Correct Answer: D
Rationale: Confusion and somnolence are beginning signs of decompensated shock. Thirst, irritability, and apprehension are signs of compensated shock.
All the following are correct about left ventricular assist device implantation, except
- A. LA pressure is reduced more than RA pressure
- B. A PFO/small ASD is created following LVAD implantation for decompressing LA
- C. Right to left shunting at atrial level can produce systemic desaturation
- D. RV failure is a bad prognostic marker
Correct Answer: B
Rationale: A PFO/small ASD is not typically created following LVAD implantation.
The following are recognised features of achondroplasia:
- A. Shortened spine
- B. Increased liability to pathological fractures
- C. Can be diagnosed radiologically at birth
- D. Infertility
Correct Answer: C
Rationale: Achondroplasia can be diagnosed radiologically at birth. The spine is not shortened, fractures are not increased, and infertility is not a feature.