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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
The nurse should expect for the insulin lispro to start working at 10-20 minutesand to peak at 1-2 hours.
Rationale: Insulin lispro is a rapid-acting insulin analog, which means it starts working relatively quickly after administration and reaches its peak effectiveness at a specific time. The onset of action for insulin lispro is typically around 10-20 minutes, meaning it begins to lower blood glucose levels within this timeframe. The peak effect occurs around 1-2 hours after administration, during which the insulin has the most potent effect on reducing blood glucose levels.
Correct Answer is A
Explanation
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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