A home health nurse is making a home visit to a client with multiple sclerosis. The nurse reviews the home medications taken by the client. Which question should the nurse ask to determine the effectiveness of the client's medication, baclofen (Lioresal)?

"Are you having any headaches?"

"How has your appetite been?"

"Does your urine look clear or cloudy? "

"Are you having trouble with spasms?"

Answer and Explanation

The Correct Answer is D

A. "Are you having any headaches?" : While headaches can be a side effect of medications, this question does not directly assess the effectiveness of baclofen. Baclofen is primarily used to reduce muscle spasms and improve muscle tone.

B. "How has your appetite been?": Changes in appetite can be related to many factors, including medication side effects, but this question does not address the primary purpose of baclofen, which is to manage muscle spasms.

C. "Does your urine look clear or cloudy?": The appearance of urine is not directly related to the effectiveness of baclofen. This question might be more relevant to assessing other conditions or medications that affect the urinary system.

D. "Are you having trouble with spasms?": Baclofen (Lioresal) is prescribed to manage and reduce muscle spasms in conditions like multiple sclerosis. Asking the client about their experience with muscle spasms directly assesses the effectiveness of the medication in managing their symptoms.

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Correct Answer is ["B","C","D"]

Explanation

A) Use a razor to shave the hair in the treated area:
Shaving the treated area with a razor is not recommended during radiation therapy. The skin in the treated area becomes sensitive and fragile, so shaving could cause irritation, cuts, or abrasions. Instead, clients are usually advised to use electric razors or avoid shaving the area altogether. This instruction should not be followed to minimize the risk of injury.

B) Wash treated area gently with lukewarm water and mild soap:
This is a key self-care instruction for clients receiving radiation. Gentle cleansing with lukewarm water and mild soap helps to avoid further irritation to the skin, which can become dry and sensitive during radiation therapy. The treated area should not be scrubbed or rubbed, as this can cause damage to the skin, exacerbate dryness, or cause skin breakdown. This guideline is appropriate and should be followed.

C) Purchase aloe-approved skin-care products:
Using aloe vera or skin-care products approved for use during radiation therapy can help soothe and moisturize the skin, which often becomes dry, irritated, or sunburned from radiation. It is important to use products that are specifically designed for use during radiation to avoid any potential irritants or allergens. Aloe-based products or products recommended by the healthcare provider can provide relief and reduce side effects.

D) Wear loose-fitting, soft clothing over the treated skin:
Wearing loose-fitting, soft clothing is a crucial self-care recommendation for clients undergoing radiation. Tight or rough fabrics can irritate the sensitive skin, potentially leading to discomfort or skin breakdown. Soft fabrics like cotton are ideal, as they allow the skin to breathe and help avoid further friction or pressure on the treated area. This is an important aspect of skin protection during radiation therapy.

E) Sun tan the affected area for no more than 30 minutes a day:
Sun tanning or exposing the treated skin to direct sunlight is strictly forbidden during and after radiation therapy. The skin in the treated area is much more sensitive to UV radiation and can burn easily, even with minimal sun exposure. It can increase the risk of skin damage and delayed healing. The client should be advised to avoid direct sun exposure entirely and to wear protective clothing and sunscreen if they must be outdoors.

A. Go to the emergency department B. Continue to use salmeterol and fluticasone as prescribed C. Administer an additional rescue dose of Albuterol D. Call the physician

Correct Answer is C

Explanation

A) Go to the emergency department:
An immediate trip to the emergency department is generally not required for a peak expiratory flow rate (PEFR) of 82%. The PEFR of 82% indicates that the client’s airflow is reduced, but it is not necessarily an emergency. PEFR readings are typically classified into zones: green (80-100% of personal best), yellow (50-79% of personal best), and red (below 50% of personal best). A reading of 82% is in the yellow zone, which suggests that the client is experiencing some degree of airway obstruction or worsening asthma symptoms

B) Continue to use salmeterol and fluticasone as prescribed:
While salmeterol (a long-acting beta agonist) and fluticasone (a corticosteroid) are important for long-term asthma control, continuing their use without additional intervention is not the most appropriate action when the PEFR is 82%. A PEFR of 82% indicates that the client’s asthma is not well controlled at the moment, and the nurse should recommend additional short-acting relief to help open the airways (e.g., a rescue inhaler like albuterol.

C) Administer an additional rescue dose of Albuterol:
The correct immediate action is to administer a rescue dose of albuterol. Albuterol is a short-acting beta-agonist that helps open the airways quickly during an asthma exacerbation. A PEFR of 82% falls in the yellow zone, suggesting some obstruction but not an emergency situation. In this case, administering an additional rescue dose of albuterol can help improve airflow and bring the PEFR closer to normal.

D) Call the physician:
While it may be necessary to call the physician if the client’s asthma symptoms do not improve after using a rescue inhaler or if there is a significant decline in symptoms, the first immediate action should be to use a rescue medication like albuterol. Calling the physician may be appropriate after assessing the response to the rescue medication, but it is not the first step in managing a PEFR of 82%.

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A home health nurse is making a home visit to a client with multiple sclerosis. The nurse reviews the home medications taken by the client. Which question should the nurse ask to determine the effectiveness of the client's medication, baclofen (Lioresal)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse discusses the self-care guidelines to minimize the side effects of radiation on the skin. Which self-care instructions can the nurse provide the client receiving radiation? [Select all that apply.]

Correct Answer is ["B","C","D"]

Explanation

A nurse instructs a 60-year-old client diagnosed with asthma about using a peak expiratory flow meter. Which immediate action should the nurse recommend to the client that obtains a reading of 82% on their peak flow meter?

Correct Answer is C

Explanation

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