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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the most significant information about this finding. St. John's Wort is an herbal supplement that is used for various conditions, such as depression, anxiety, or insomnia. However, it can also interact with many medications, including cyclosporine, which is an immunosuppressant drug that is used to prevent organ rejection after transplantation. St. John's Wort can induce the activity of certain enzymes in the liver that metabolize cyclosporine, leading to lower levels of the drug in the blood and reduced efficacy. This can increase the risk of graft rejection and complications. The nurse should inform the healthcare provider and educate the client about the potential interaction and the importance of avoiding St. John's Wort and other herbal products without consulting the provider.
Choice B reason: This is not significant information about this finding. Adding the herb can not decrease the need for corticosteroids, which are another type of immunosuppressant drug that are used to prevent organ rejection after transplantation. St. John's Wort does not have any anti-inflammatory or immunomodulatory effects that can reduce the dosage or frequency of corticosteroids. On the contrary, it can interfere with the metabolism and absorption of corticosteroids, as well as other medications, and cause adverse effects or reduced efficacy. The nurse should advise the client to follow the prescribed regimen of corticosteroids and other drugs, and not to self-medicate with herbal products.
Choice C reason: This is not significant information about this finding. The client probably used this herb to treat depression, which is a common condition among transplant recipients, due to the stress, anxiety, and lifestyle changes associated with the procedure. However, this does not explain the cause of the graft rejection, nor does it justify the use of St. John's Wort without consulting the healthcare provider. St. John's Wort is not a proven or safe treatment for depression, and it can interact with many antidepressant drugs, such as selective serotonin reuptake inhibitors (SSRIs), and cause serious side effects, such as serotonin syndrome. The nurse should assess the client's mental health status and refer the client to a mental health professional if needed.
Choice D reason: This is not a significant information about this finding. Ingestion of St. John's Wort can not reduce the client's intake of sodium, which is an electrolyte that is essential for the fluid balance and nerve function in the body. St. John's Wort does not have any diuretic or sodium-lowering effects that can affect the sodium levels in the blood or urine. The nurse should monitor the client's sodium levels and fluid intake and output, and report any abnormal findings to the healthcare provider. The nurse should also teach the client about the dietary sources and recommendations of sodium, and the signs and symptoms of hyponatremia or hypernatremia.
Correct Answer is A
Explanation
Choice A reason: This is the correct manifestation for the nurse to identify as a reason to stop the infusion. A scratchy throat may indicate an allergic reaction to piperacillin-tazobactam, which is a penicillin derivative. The client may also develop other signs of anaphylaxis, such as rash, itching, swelling, wheezing, or difficulty breathing. The nurse should stop the infusion immediately and notify the healthcare provider.
Choice B reason: This is not a correct manifestation for the nurse to identify as a reason to stop the infusion. Pupillary constriction is not a common or serious side effect of piperacillin-tazobactam. It may be caused by other factors, such as light exposure, medication use, or neurological conditions. The nurse should monitor the client's pupils for any changes, but it is not a reason to stop the infusion.
Choice C reason: This is not a correct manifestation for the nurse to identify as a reason to stop the infusion. Bradycardia, or a slow heart rate, is not a common or serious side effect of piperacillin-tazobactam. It may be caused by other factors, such as cardiac disorders, medication use, or vagal stimulation. The nurse should monitor the client's vital signs for any changes, but it is not a reason to stop the infusion.
Choice D reason: This is not a correct manifestation for the nurse to identify as a reason to stop the infusion. Hypertension, or high blood pressure, is not a common or serious side effect of piperacillin-tazobactam. It may be caused by other factors, such as stress, pain, or renal disorders. The nurse should monitor the client's blood pressure for any changes, but it is not a reason to stop the infusion.
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