A client on alcohol withdraw protocol suddenly begins to have a seizure in his bed. After several minutes the seizure has not ended and the nurse suspects the client is suffering from status epilepticus. What is the priority action the nurse will take?

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.

Choice A rationale: Indicated. This is important for a client with type 1 diabetes, as counting carbohydrates helps in calculating the appropriate insulin dose and maintaining glycemic control.

Choice B rationale: Non-essential. The client is already admitted to the surgical floor and does not require restarting the IV fluids unless there is a specific medical indication.

Choice C rationale: Contraindicated. Insulin doses should be prescribed by a healthcare provider based on the patient's blood glucose levels and individual insulin requirements. The nurse should follow the prescribed insulin orders and not administer insulin without an order.

Choice D rationale: Indicated. Insulin glargine is a long-acting basal insulin used to provide a steady background insulin level throughout the day. The nurse should administer the prescribed insulin glargine dose as ordered.

Choice E rationale: Contraindicated. Insulin lispro is a rapid-acting insulin, and insulin glargine is a long-acting insulin. Mixing different types of insulin in one syringe can alter their pharmacokinetics and lead to inconsistent blood glucose control. Insulin lispro and insulin glargine should be administered separately.