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

Evaluate muscle strength every 4 hours.

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

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

Monitor intake and output every 8 hours.

Answer and Explanation

The Correct Answer is B

A. Evaluate muscle strength every 4 hours: While assessing muscle strength is important in clients with multiple sclerosis, it does not need to be done this frequently unless the client is unstable. Baclofen may cause weakness, but routine assessments every 4 hours are excessive for stable patients.

B. Advise the client to move slowly and cautiously when rising and walking: Baclofen can cause dizziness, sedation, decreased muscle tone and orthostatic hypotension, particularly in the early stages of treatment. Educating the client to change positions carefully helps reduce the risk of falls and injury.

C. Ensure the client knows to stop baclofen before using other antispasmodics: Baclofen should not be stopped abruptly due to the risk of withdrawal symptoms like hallucinations or seizures. Combining different antispasmodic medications can increase the risk of adverse effects such as excessive sedation or muscle weakness. Medication changes therefore should only be made under the supervision of the healthcare provider.

D. Monitor intake and output every 8 hours: Baclofen does not typically affect renal function or fluid balance significantly. Monitoring intake and output is not a standard intervention specific to baclofen administration unless there is another underlying condition.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Start the second course of therapy after an 8-week delay: While a second course of isotretinoin may sometimes be considered after a break if acne persists, this timing is medication management guidance and is less urgent than immediate safety concerns like sun sensitivity.

B. Consider an alternative summer job, other than life guarding: Isotretinoin causes extreme photosensitivity, making prolonged sun exposure dangerous. Adolescents working outdoors, like lifeguards, are at high risk for severe sunburns, so suggesting alternative employment protects their health.

C. Store the medicine in a plastic, tight, light resistant container: Proper medication storage is important but not the most critical concern compared to preventing serious adverse effects like sunburn, teratogenicity, or psychiatric symptoms with isotretinoin use.

D. Discontinue all multivitamins during acne medication therapy: There is generally no need to discontinue all multivitamins while taking isotretinoin unless specifically instructed by the healthcare provider. Some multivitamins contain vitamin A, excessive intake of vitamin A should be avoided. However, discontinuing all multivitamins without guidance could lead to other nutritional deficiencies.

Correct Answer is []

Explanation

Methemoglobinemia: Methemoglobinemia is characterized by hypoxia symptoms despite normal oxygen saturation readings. However, this condition is very rare in asthma patients and is typically associated with certain medications or chemical exposures, not beta-agonist overuse like albuterol.
Anemia: Anemia could cause dizziness and lightheadedness, but it would not explain palpitations triggered by excessive albuterol use. The acute worsening of symptoms with a background of asthma and heavy beta-agonist use points away from anemia as the primary concern.
Anaphylaxis: Anaphylaxis presents with airway swelling, hypotension, wheezing, and respiratory compromise. Since the client’s oxygen saturation is excellent (99%) and no wheezing or airway edema is noted, anaphylaxis is unlikely in this scenario.
Tachydysrhythmia: Tachydysrhythmia is the most likely diagnosis because overuse of albuterol stimulates beta receptors, leading to increased heart rate, palpitations, dizziness, and lightheadedness. This aligns precisely with the client's reported symptoms and assessment findings.
Administer diphenhydramine: Diphenhydramine is an antihistamine used primarily for allergic reactions and anaphylaxis. There is no evidence of an allergic process in this client; thus, administering diphenhydramine would not address the cardiac symptoms from probable tachydysrhythmia.
Give a dose of albuterol: Administering more albuterol would likely worsen the tachydysrhythmia, as beta-agonists increase heart rate and myocardial oxygen demand. Since the problem stems from albuterol overuse, giving another dose would be inappropriate and harmful.
Take a set of baseline vital signs: Taking a set of baseline vital signs is essential because it provides a foundation for assessing current cardiovascular stability. It would help establish the severity of the tachycardia and guide further intervention strategies.
Place the client on a cardiorespiratory monitor: Placing the client on a cardiorespiratory monitor is critical to continuously assess heart rate, rhythm, and potential arrhythmias. This allows immediate detection of life-threatening patterns such as supraventricular tachycardia or ventricular ectopy.
Draw blood for a complete blood count: Drawing a CBC would help if there was suspicion of anemia or infection, but the clinical picture points primarily toward a cardiac rhythm problem. This diagnostic step would not be immediately necessary based on the current situation.
Methemoglobin level: Monitoring methemoglobin levels would be appropriate if the client had cyanosis or unexplained hypoxia without respiratory distress. Since the oxygen saturation is excellent, checking methemoglobin is not relevant to her current condition.
Iron level: Monitoring iron levels is important in diagnosing chronic anemia, but anemia is not the primary issue here. The focus should remain on cardiovascular monitoring because the immediate symptoms suggest arrhythmia rather than a hematologic cause.
Breath sounds: Although the client currently has no wheezing, regular assessment of breath sounds is necessary to detect any developing bronchospasm or respiratory deterioration, especially given her underlying asthma diagnosis and recent respiratory strain.
Airway edema: Monitoring for airway edema would be essential if anaphylaxis were suspected. Since there are no signs of respiratory distress, stridor, or swelling, airway edema monitoring is less relevant compared to cardiac monitoring in this situation.
Heart rate and rhythm: Heart rate and rhythm must be continuously monitored because the client is exhibiting signs of tachydysrhythmia. Detecting arrhythmias early enables prompt treatment and reduces the risk of serious cardiac complications like syncope or cardiac arrest.

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

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Correct Answer is []

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