The nurse is administering the muscle relaxant baclofen orally to a patient diagnosed with multiple sclerosis. What intervention should the nurse implement?

Advise the patient to move slowly and cautiously when getting up and walking.

Evaluate the patient’s muscle strength every 4 hours.

Monitor the patient’s intake and output every 8 hours.

Ensure the patient understands to stop taking baclofen before using other antispasmodics.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Baclofen is a muscle relaxant used to treat muscle symptoms caused by multiple sclerosis (MS), including spasm, pain, and stiffness. It acts on the central nervous system to relieve spasticity, improving muscle movement and relieving pain from spasticity. One of the common side effects of Baclofen is drowsiness, dizziness, and weakness. Therefore, advising the patient to move slowly and cautiously when getting up and walking is an important nursing intervention to prevent falls and injuries.

Choice B rationale

While evaluating the patient’s muscle strength every 4 hours can provide valuable information about the patient’s response to treatment, it is not the most critical intervention in this context. Baclofen’s primary effect is to relieve spasticity, not necessarily to increase muscle strength.

Choice C rationale

Monitoring the patient’s intake and output every 8 hours is a standard nursing intervention for many patients, but it is not specifically related to the administration of baclofen.

Choice D rationale

While it’s important for patients to understand their medication regimen, including when to stop taking certain medications, baclofen should not be stopped abruptly. Abrupt discontinuation has resulted in serious adverse reactions including death. Therefore, ensuring the patient understands to stop taking baclofen before using other antispasmodics is not the correct intervention.

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Correct Answer is B

Explanation

Choice A rationale

Instructing the patient to exhale rapidly into the mouthpiece when using the discus is incorrect. The patient should breathe in through their mouth as deeply as they can until they have taken a full deep breath.

Choice B rationale

Fluticasone and salmeterol is a combination of two medicines that are used to help control the symptoms of asthma and improve breathing. It is used when a patient’s asthma has not been controlled sufficiently on other asthma medicines, or when a patient’s condition is so severe that more than one medicine is needed every day. Therefore, explaining that the patient should not use the discus more than twice daily is the correct instruction.

Choice C rationale

Informing that patients using the discus may experience a decrease in blood pressure is incorrect. The most common side effects of fluticasone and salmeterol include drowsiness, dizziness, and weakness.

Choice D rationale

Suggesting offering the discus to the patient for use during an acute asthma attack is incorrect. Fluticasone and salmeterol is not used to relieve an asthma attack that has already started.

A. Praise the patient for her healthy lifestyle and encourage her to maintain her current dietary habits. B. Assure the patient that her dietary choices will enhance the effectiveness of the medication in preventing blood clots. C. Inform the patient that her healthcare provider needs to be informed about her current diet. D. Recommend that the patient substitutes the leafy vegetables with a protein source like nuts or beans.

Correct Answer is C

Explanation

Choice A rationale

While maintaining a healthy lifestyle and diet is generally beneficial, consuming large amounts of leafy green vegetables, which are high in vitamin K, can interfere with the effectiveness of warfarin, a medication that works by inhibiting the action of vitamin K-dependent clotting factors. Therefore, praising the patient for her healthy lifestyle without addressing the potential interaction between her diet and medication could lead to suboptimal treatment outcomes.

Choice B rationale

This statement is misleading. While a healthy diet can contribute to overall health and well- being, the patient’s dietary choices, specifically her daily consumption of leafy green

vegetables, could actually decrease the effectiveness of warfarin. Warfarin’s ability to prevent blood clots is dependent on a consistent intake of vitamin K67.

Choice C rationale

This is the most appropriate response. The healthcare provider should be informed about the patient’s current diet because it could impact the effectiveness of warfarin. The provider may need to adjust the dose of warfarin or provide additional dietary guidance to ensure the medication works as intended.

Choice D rationale

While this might seem like a reasonable suggestion, it’s important to remember that dietary changes should be made in consultation with a healthcare provider or a dietitian. Substituting leafy green vegetables with other protein sources may not be necessary or appropriate depending on the patient’s overall diet, nutritional needs, and personal preferences.

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The nurse is administering the muscle relaxant baclofen orally to a patient diagnosed with multiple sclerosis. What intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient in a residential treatment facility uses a fluticasone propionate and salmeterol discus inhalation system to manage asthma.This system delivers an inhaled powdered form of these combined medications. What instruction should the nurse provide to this patient’s caregivers?

Correct Answer is B

Explanation

A female patient who follows a vegetarian diet has recently been prescribed warfarin. She mentions that she consumes leafy green vegetables daily.What should be the nurse’s response?

Correct Answer is C

Explanation

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