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 A
Explanation
A:The primary therapeutic effect of epoetin alfa is to stimulate erythropoiesis, leading to an increase in hemoglobin levels. An increase to 12 g/dL demonstrates that the medication is effectively treating the anemia caused by CKD. Monitoring hemoglobin levels is the most objective and reliable indicator of the medication’s effectiveness.
B: While these subjective improvements can indicate an overall improvement in anemia-related symptoms, they are not the best or most definitive measure of the medication's effectiveness. Objective data, such as hemoglobin levels, provide more concrete evidence.
C: Increased consumption of iron-rich foods is beneficial for clients with anemia, but it is not a direct indicator of the effectiveness of epoetin alfa. Dietary changes can support overall health but do not provide evidence of the medication's impact on hemoglobin levels.
D: Taking concurrent iron therapy is common for clients receiving epoetin alfa, as iron is necessary for the production of red blood cells. However, the absence of adverse effects does not directly indicate the effectiveness of epoetin alfa in increasing hemoglobin levels.
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.
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