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

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

Monitor intake and output every 8 hours.

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

Evaluate muscle strength every 4 hours.

Answer and Explanation

The Correct Answer is A

Choice A rationale: Baclofen is a muscle relaxant used to reduce muscle spasticity in conditions such as multiple sclerosis. One of the common side effects of baclofen is dizziness or orthostatic hypotension, which can increase the risk of falls. Therefore, the nurse should advise the client to move slowly and cautiously when rising and walking to prevent falls and injury.

Choice B rationale: Monitoring intake and output every 8 hours is not directly related to the administration of baclofen.

Choice C rationale: Ensuring the client knows to stop baclofen before using other antispasmodics is not the correct intervention. Baclofen should not be abruptly discontinued without medical advice, and its use should be discussed with the healthcare provider.

Choice D rationale: Evaluating muscle strength every 4 hours may be part of the client's overall care plan, but it is not directly related to the administration of baclofen. Muscle strength evaluation is more pertinent for assessing the progression of multiple sclerosis and its effects on muscle function.

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Correct Answer is C

No explanation

A. Administer both prescribed medications as scheduled. B. Hold both medications until contacting the healthcare provider. C. Hold the calcium carbonate, but administer the calcitriol as scheduled. D. Hold the, calcitriol but administer the calcium carbonate as scheduled.

Correct Answer is B

Explanation

Choice A rationale: This is not appropriate because the client's elevated calcium level requires immediate attention and further assessment by the healthcare provider before administering any medications that may further raise calcium levels.

Choice B rationale: The client's total calcium level is significantly elevated, which may indicate hypercalcemia. Given the reference range for total calcium in adults is 9 to 10.5 mg/dL (2.25 to 2.62 mmol/L), a calcium level of 14 mg/dL (3.5 mmol/L) is abnormally high. Both calcitriol (active form of vitamin D) and calcium carbonate (calcium supplement) can increase calcium levels in the body. Before administering any medication, the nurse should hold both calcitriol and calcium carbonate and notify the healthcare provider of the elevated calcium level. The healthcare provider will determine the appropriate course of action and may adjust the dosage or temporarily discontinue the medications to prevent further complications related to hypercalcemia.

Choice C rationale: Holding calcium carbonate is a step in the right direction, but given the significant elevation of total calcium, it is best to hold both medications and consult the healthcare provider.

Choice D rationale: Holding calcitriol is a step in the right direction, but both medications should be held to prevent exacerbation of hypercalcemia until further instructions are received from the healthcare provider.

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

Nursing Test Bank

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