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

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

Monitor intake and output every 8 hours.

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

Evaluate muscle strength every 4 hours.

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

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.

A. Assess the client for side effects of carbamazepine. B. Notify the healthcare provider of the carbamazepine level. C. Administer the carbamazepine as prescribed. D. Withhold this dose of the carbamazepine.

Correct Answer is C

Explanation

a) Assess the client for side effects of carbamazepine:

This option might seem reasonable as monitoring for side effects is essential with any medication, especially one with a narrow therapeutic range like carbamazepine. However, the client's level of 8.4 mcg/L is within the therapeutic range (4 to 12 mcg/mL), so there's no immediate indication that side effects are likely to occur solely based on this level.

b) Notify the healthcare provider of the carbamazepine level:

While it's important to keep the healthcare provider informed about the client's condition, in this case, the carbamazepine level is within the therapeutic range. There's no urgent need to notify the provider unless there are other concerning factors not mentioned in the scenario.

c) Administer the carbamazepine as prescribed:

This is the correct answer. The client's morning carbamazepine level of 8.4 mcg/L falls within the therapeutic range (4 to 12 mcg/mL). Therefore, the evening dose should be administered as prescribed to maintain therapeutic levels and control the client's condition.

d) Withhold this dose of the carbamazepine:

Withholding the dose based solely on the morning carbamazepine level of 8.4 mcg/L, which is within the therapeutic range, would not be appropriate. Withholding the dose without consulting the healthcare provider could potentially lead to suboptimal management of the client's condition.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

Prior to administering the evening dose of carbamazepine, the nurse notes that the client's morning carbamazepine level was 8.4 mcg/L (35.6 mcmol/L). Which action should the nurse take? Carbamazepine level [Reference Range: 4 to 12 mcg/mL or 16.9 to 50.8 mcmol/L]

Correct Answer is C

Explanation

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