The nurse is administering muscle relaxant baclofen by mouth (PO) to a client diagnosed with multiple sclerosis. Which intervention is the most important for the nurse to implement?

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

Evaluate muscle strength every 4 hours.

Monitor intake and output every 8 hours.

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

Answer and Explanation

The Correct Answer is A

Choice A reason: Baclofen is a muscle relaxant that can cause drowsiness, dizziness, and orthostatic hypotension. These side effects can increase the risk of falls and injuries for the client. Therefore, the nurse should advise the client to move slowly and cautiously when rising and walking, and to use assistive devices if needed.

Choice B reason: Evaluating muscle strength every 4 hours is not the most important intervention for the nurse to implement, as baclofen does not affect muscle strength directly. It may reduce muscle spasticity and stiffness, but it does not improve muscle function or coordination.

Choice C reason: Monitoring intake and output every 8 hours is not the most important intervention for the nurse to implement, as baclofen does not have a significant effect on fluid balance or renal function. However, the nurse should monitor the client for signs of urinary retention, which is a rare but possible adverse effect of baclofen.

Choice D reason: Ensuring the client knows to stop baclofen before using other antispasmodics is not the most important intervention for the nurse to implement, as baclofen can be used in combination with other antispasmodics under medical supervision. However, the nurse should educate the client about the potential drug interactions and contraindications of baclofen, and to consult the prescriber before taking any new medications.

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Correct Answer is C

Explanation

Choice A reason: This is not a correct information for the nurse to include in the discharge instructions. Taking the tablet with a daily multivitamin is not advisable, as some vitamins and minerals, such as calcium, zinc, and vitamin C, can interfere with the absorption of iron and reduce its effectiveness. The client should take the tablet on an empty stomach or with a small amount of food that does not contain these substances.

Choice B reason: This is not a correct information for the nurse to include in the discharge instructions. Bedtime is not the best time to take the tablet, as it may cause gastrointestinal side effects, such as nausea, vomiting, constipation, or diarrhea, that can disrupt the client's sleep and comfort. The client should take the tablet at least 2 hours before or after meals, and preferably in the morning.

Choice C reason: This is a correct information for the nurse to include in the discharge instructions. Waiting 2 hours after meals to take the tablet is recommended, as it ensures that the stomach is empty and that the iron is not affected by any food or beverages that may impair its absorption. The client should also drink plenty of water with the tablet to facilitate its passage and prevent irritation of the esophagus.

Choice D reason: This is not a correct information for the nurse to include in the discharge instructions. Crushing the tablets and mixing with pudding is not appropriate, as it can damage the enteric coating of the tablets, which is designed to protect the iron from being destroyed by the stomach acid and to reduce the gastrointestinal side effects. The client should swallow the tablets whole and not chew, break, or crush them.

A. Administer both prescribed medications as scheduled. B. Hold the calcium carbonate, but administer the calcitriol as scheduled. C. Hold both medications until contacting the healthcare provider. D. Hold the calcitriol, but administer the calcium carbonate as scheduled.

Correct Answer is C

Explanation

Choice A reason: Administering both prescribed medications as scheduled is not the appropriate action in this situation. The client's total calcium level is above the normal range of 9 to 10.5 mg/dL (2.25 to 2.62 mmol/L), indicating hypercalcemia. Hypercalcemia is a serious condition that can cause nausea, vomiting, constipation, confusion, kidney stones, and cardiac arrhythmias. Giving more calcitriol and calcium carbonate would worsen the client's condition and increase the risk of complications.

Choice B reason: Holding the calcium carbonate, but administering the calcitriol as scheduled is not the appropriate action in this situation. Calcium carbonate is a supplement that provides extra calcium to the body. Calcitriol is a synthetic form of vitamin D that helps the body absorb calcium from the intestines and kidneys. Both medications can increase the blood calcium level and cause hypercalcemia. The nurse should not give either medication without consulting the healthcare provider.

Choice C reason: Holding both medications until contacting the healthcare provider is the best action in this situation. The nurse should recognize that the client's total calcium level is dangerously high and report it to the healthcare provider as soon as possible. The healthcare provider may order to stop or adjust the doses of calcitriol and calcium carbonate, and prescribe other treatments to lower the blood calcium level, such as intravenous fluids, diuretics, or bisphosphonates.

Choice D reason: Holding the calcitriol, but administering the calcium carbonate as scheduled is not the appropriate action in this situation. Calcium carbonate is a supplement that provides extra calcium to the body. Giving more calcium carbonate to a client with hypercalcemia would increase the blood calcium level even more and cause more harm. The nurse should not give any medication that can raise the blood calcium level without consulting the healthcare provider.

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The nurse is administering muscle relaxant baclofen by mouth (PO) to a client diagnosed with multiple sclerosis. Which intervention is the most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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