The nurse is administering muscle relaxant baclofen by mouth (PO) to a client diagnosed with multiple sclerosis. Which intervention is the most important for the nurse to implement?

Advise the client to move slowly and cautiously when rising and walking.

Evaluate muscle strength every 4 hours.

Monitor intake and output every 8 hours.

Ensure the client knows to stop baclofen before using other antispasmodics.

Answer and Explanation

The Correct Answer is A

Choice A reason: Baclofen is a muscle relaxant that can cause drowsiness, dizziness, and orthostatic hypotension. These side effects can increase the risk of falls and injuries for the client. Therefore, the nurse should advise the client to move slowly and cautiously when rising and walking, and to use assistive devices if needed.

Choice B reason: Evaluating muscle strength every 4 hours is not the most important intervention for the nurse to implement, as baclofen does not affect muscle strength directly. It may reduce muscle spasticity and stiffness, but it does not improve muscle function or coordination.

Choice C reason: Monitoring intake and output every 8 hours is not the most important intervention for the nurse to implement, as baclofen does not have a significant effect on fluid balance or renal function. However, the nurse should monitor the client for signs of urinary retention, which is a rare but possible adverse effect of baclofen.

Choice D reason: Ensuring the client knows to stop baclofen before using other antispasmodics is not the most important intervention for the nurse to implement, as baclofen can be used in combination with other antispasmodics under medical supervision. However, the nurse should educate the client about the potential drug interactions and contraindications of baclofen, and to consult the prescriber before taking any new medications.

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Correct Answer is B

Explanation

Choice A reason: Ginkgo biloba use should be limited and not taken during pregnancy is a true statement, but not the most important information for the nurse to include in the teaching plan. Ginkgo biloba may have adverse effects on the fetus, such as bleeding, seizures, or malformations. However, this information is only relevant if the client is pregnant or planning to become pregnant. The nurse should assess the client's reproductive status and advise her accordingly.

Choice B reason: Aspirin and non-steroidal anti-inflammatory drugs interact with ginkgo is the most important information for the nurse to include in the teaching plan. Ginkgo biloba has antiplatelet and anticoagulant properties, which means it can prevent blood clots from forming. However, this also increases the risk of bleeding, especially when combined with other drugs that affect blood clotting, such as aspirin and non-steroidal anti-inflammatory drugs (NSAIDs). The nurse should instruct the client to avoid taking these drugs with ginkgo biloba and inform the healthcare provider of all the medications and supplements she is using.

Choice C reason: Nausea and diarrhea can occur when using this supplement is a possible side effect of ginkgo biloba, but not the most important information for the nurse to include in the teaching plan. Nausea and diarrhea are usually mild and transient, and can be reduced by taking ginkgo biloba with food or water. The nurse should inform the client of this possibility and advise her to report any severe or persistent symptoms to the healthcare provider.

Choice D reason: Anxiety and headaches increase with the use of ginkgo biloba is a false statement, and not the information for the nurse to include in the teaching plan. Ginkgo biloba may actually have beneficial effects on anxiety and headaches, as it can improve blood circulation and oxygen delivery to the brain. The nurse should not discourage the client from using ginkgo biloba for these reasons, unless there is a contraindication or an interaction with other drugs.

A. Apply oxygen face mask. B. Remove the morphine patches. C. Administer a narcotic reversal drug. D. Monitor blood pressure.

Correct Answer is B

Explanation

Choice A reason: This is not the first action for the nurse to take. Applying oxygen face mask may help the client with shortness of breath, but it does not address the underlying cause of the respiratory depression, which is the overdose of morphine. The nurse should first remove the source of the excess morphine and then provide oxygen therapy as needed.

Choice B reason: This is the first action for the nurse to take. Removing the morphine patches is the most urgent and effective way to stop the further absorption of the drug and reduce the risk of life-threatening complications, such as respiratory arrest, coma, or death. The nurse should remove all the patches from the client's body and dispose of them safely. The nurse should also notify the healthcare provider and prepare to administer a narcotic reversal drug, such as naloxone, if indicated.

Choice C reason: This is not the first action for the nurse to take. Administering a narcotic reversal drug may be necessary to reverse the effects of the morphine overdose, but it is not the most immediate intervention. The nurse should first remove the morphine patches to prevent further exposure and then assess the client's level of consciousness, respiratory rate, and oxygen saturation. The nurse should follow the healthcare provider's orders and the facility's protocol for administering a narcotic reversal drug.

Choice D reason: This is not the first action for the nurse to take. Monitoring blood pressure may be important to assess the client's hemodynamic status, but it is not the most critical intervention. The nurse should first remove the morphine patches to prevent further deterioration and then monitor the client's vital signs, including blood pressure, pulse, and temperature. The nurse should also watch for signs of hypotension, shock, or cardiac arrest.

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The nurse is administering muscle relaxant baclofen by mouth (PO) to a client diagnosed with multiple sclerosis. Which intervention is the most important for the nurse to implement?

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Naxlex Comprehensive Predictor Exams

A female client with multiple sclerosis reports having less fatigue and improved memory since she began using the herbal supplement, ginkgo biloba. Which information is most important for the nurse to include in the teaching plan for this client?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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