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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale; Family history of mental illness is important information to consider when assessing the client's overall mental health history, but it is not directly related to the immediate safety and effectiveness of duloxetine.
Choice B rationale: Weight change in the last month is relevant to monitoring for side effects of duloxetine, but it is not as critical as assessing liver function, which directly impacts the metabolism of the medication.
Choice C rationale: When planning care for a client starting on duloxetine, it is most important for the nurse to obtain liver function laboratory results. Duloxetine is primarily metabolized in the liver, and it is important to assess the client's liver function before starting the medication to ensure that the liver can process the drug effectively and safely. Clients with impaired liver function may require dose adjustments or be at higher risk for adverse effects, so obtaining liver function test results is crucial for safe medication management.
Choice D rationale: Recent use of other antidepressants is essential to avoid potential drug interactions, but it is not the most critical piece of information compared to assessing liver function, which directly affects the client's ability to process duloxetine.
Correct Answer is B
Explanation
Choice A rationale: This option is not appropriate as increasing saturated fat intake would exacerbate the oily stool and flatus symptoms caused by orlistat. Orlistat is specifically designed to reduce fat absorption, and increasing fat intake would be counterproductive and may worsen the side effects.
Choice B rationale: Asking a client to describe their dietary intake history is a standard practice in nutritional assessment. It provides a baseline for understanding current eating habits and identifying areas for improvement.
Choice C rationale: Advising a client to stop taking medication should only be done by a qualified healthcare provider who has full knowledge of the client's health history and current medications.
Choice D rationale: While obtaining a stool specimen for evaluation might be relevant in some situations, it is not the priority in this case. The oily stools and flatus are most likely related to the side effects of orlistat and do not typically require stool testing for confirmation. The more immediate action would be to address the symptoms by advising the client to stop taking the medication and contact her healthcare provider for further guidance.
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