A client is receiving baclofen for the management of symptoms associated with multiple sclerosis. To evaluate the effectiveness of this medication, what does the nurse assess?
Muscle spasms
Mood and affect
Appetite
Sleep pattern
The Correct Answer is A
Choice A reason:
Baclofen is primarily used to treat muscle symptoms caused by multiple sclerosis, including muscle spasms, stiffness, and pain1. It acts on the spinal cord nerves to decrease the number and severity of muscle spasms, thereby improving muscle movement2. The effectiveness of baclofen in managing multiple sclerosis symptoms is best evaluated by assessing the reduction in muscle spasms.
Choice B reason:
While mood and affect are important aspects of a patient’s overall well-being, they are not the primary indicators of baclofen’s effectiveness. Baclofen does not have a direct impact on mood and affect, as its main function is to relieve muscle spasms and improve muscle movement.
Choice C reason:
Appetite is not a primary concern when evaluating the effectiveness of baclofen. This medication is not known to significantly affect appetite. The main therapeutic goal of baclofen is to reduce muscle spasms and improve mobility in patients with multiple sclerosis.
Choice D reason:
Sleep pattern, although important for overall health, is not the primary measure of baclofen’s effectiveness. Baclofen’s primary role is to alleviate muscle spasms and improve muscle function. While it may have some impact on sleep due to its muscle-relaxing properties, this is not the main criterion for evaluating its effectiveness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","J"]
Explanation
Intervention: Validate that informed consent has been given by the client.
Reason: Before any invasive procedure, it is crucial to ensure that the client has given informed consent. This means the client understands the procedure, its risks, benefits, and any potential complications. Validating informed consent is a legal and ethical requirement that ensures the client is making an informed decision about their care12.
Assessment: The trachea is shifted away from the midline of the neck.
Reason: A tracheal shift is a critical finding that warrants immediate action. It can indicate a tension pneumothorax, which is a life-threatening condition where air accumulates in the pleural space and causes the lung to collapse. This shift can compromise respiratory function and requires urgent intervention34.
Choice B: Pulse oximetry is 93% on 2 L of oxygen.
Reason: While a pulse oximetry reading of 93% on 2 liters of oxygen is slightly below the normal range (95-100%), it is not immediately life-threatening. However, it does indicate that the client may need further evaluation and monitoring to ensure adequate oxygenation.
Choice C: The client rates pain as 8/10 at the site of the procedure.
Reason: Pain management is important, but an 8/10 pain rating at the procedure site, while significant, does not require immediate action compared to a tracheal shift. Pain can be managed with appropriate analgesics as ordered by the physician.
Choice D: Request an order for pain medication.
Reason: Requesting an order for pain medication is a necessary intervention for managing the client’s pain, but it is not as urgent as addressing a tracheal shift. Pain management should be part of the overall care plan.
Choice E: Measure oxygen saturation before and after a 12-minute walk.
Reason: Measuring oxygen saturation before and after a 12-minute walk is a useful assessment to evaluate the client’s respiratory function and endurance. However, it is not an immediate priority compared to ensuring informed consent and addressing critical findings.
Choice F: Explain the procedure in detail to the client and the family.
Reason: Explaining the procedure in detail to the client and their family is essential for informed consent and reducing anxiety. It ensures that the client understands what to expect and can make an informed decision about their care.
Choice G: Assist the client to the bathroom.
Reason: Assisting the client to the bathroom is a routine nursing intervention that ensures the client’s comfort and dignity. However, it is not a priority compared to addressing critical findings and ensuring informed consent.
Choice H: Discuss all possible complications with the client.
Reason: Discussing all possible complications with the client is part of the informed consent process. It ensures that the client is aware of potential risks and can make an informed decision about their care.
Choice I: A small amount of drainage from the site is noted.
Reason: Noting a small amount of drainage from the site is an important assessment, but it is not as urgent as addressing a tracheal shift. The drainage should be monitored and documented, and any significant changes should be reported to the physician.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A reason: Monitoring the heart rate is crucial when administering amiodarone, as this drug can cause bradycardia (a slower than normal heart rate). Amiodarone affects the electrical conduction system of the heart, and close monitoring helps ensure that the heart rate remains within a safe range. The normal resting heart rate for adults is typically between 60 and 100 beats per minute.
Choice B reason: Respiratory rate monitoring is essential because amiodarone can cause pulmonary toxicity, which may manifest as interstitial pneumonitis or pulmonary fibrosis. Early detection of respiratory changes can help prevent severe complications. The normal respiratory rate for adults is 12 to 20 breaths per minute.
Choice C reason: Monitoring heart rhythm is necessary because amiodarone is used to treat arrhythmias, and it can also cause new arrhythmias or exacerbate existing ones. Continuous ECG monitoring helps detect any abnormal rhythms early, allowing for prompt intervention. Normal sinus rhythm is characterized by a regular rhythm with a rate of 60 to 100 beats per minute.
Choice D reason: Cardiac output monitoring is important because amiodarone can affect the contractility of the heart and overall cardiac function. Cardiac output is a measure of the amount of blood the heart pumps in one minute, and it is crucial for ensuring adequate tissue perfusion. Normal cardiac output ranges from 4 to 8 liters per minute in adults.
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