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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Temperature of 100.8° F (38.2° C): A mildly elevated temperature in a post-transplant client may suggest infection or early rejection, both of which warrant monitoring. However, this is not a direct reason to withhold cyclosporine, which is essential for preventing organ rejection.
B. Elevated blood urea nitrogen (BUN): Elevated BUN could indicate impaired renal function, which should be monitored during cyclosporine therapy. However, this alone is not an urgent reason to withhold the medication without further evaluation of kidney function trends and symptoms.
C. Renal output of 120 mL/hour: This is a healthy urine output and suggests good renal perfusion and function. It does not present any contraindication to continuing cyclosporine and supports that the transplanted kidney is functioning well.
D. Blood pressure 180/98 mm Hg: Hypertension is a known side effect of cyclosporine and can become severe. A blood pressure this high, especially when accompanied by headache and blurred vision, suggests possible cyclosporine-induced hypertensive crisis or toxicity, and warrants immediate withholding of the medication and notification of the HCP.
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
