The nurse is administering the muscle relaxant baclofen orally to a patient diagnosed with multiple sclerosis. What intervention should the nurse implement?

Choice A rationale

Obtaining an extra pillow for the client to use at night may provide some comfort, but it does not address the underlying issue. The client’s continual rubbing of the back of the neck could be a sign of a condition known as akathisia, a common side effect of antipsychotic medications. Akathisia is characterized by a feeling of restlessness and a compulsion to move, and it can often be misinterpreted as anxiety or agitation.

Choice B rationale

Administering a PRN prescription for benztropine is the most appropriate intervention. Benztropine is an anticholinergic medication that is often used to manage the extrapyramidal side effects of antipsychotic medications, such as akathisia. By reducing these side effects, the client’s comfort and adherence to the antipsychotic medication regimen can be improved.

Choice C rationale

Providing the client with a heating pad to place on the neck may offer temporary relief, but it does not address the underlying issue. The client’s continual rubbing of the back of the neck is likely a symptom of akathisia, a side effect of antipsychotic medications. Therefore, interventions should be aimed at managing this side effect rather than just addressing the symptom.

Choice D rationale

Obtaining a prescription for physical therapy services is not the most appropriate immediate response. While physical therapy can be beneficial for many conditions, it is not typically used as the first-line treatment for akathisia, a common side effect of antipsychotic medications.

Choice A rationale

Administering glucagon prior to meals to prevent hyperglycemia is not a recommended use of a glucagon emergency kit. Glucagon is a hormone that raises blood glucose levels by causing the liver to release stored glucose into the bloodstream. It is typically used to treat severe hypoglycemia (low blood sugar), not to prevent hyperglycemia (high blood sugar).

Choice B rationale

The nurse should instruct the client and family to administer glucagon when symptoms of severe hypoglycemia are present. Severe hypoglycemia is a potentially life-threatening condition that can cause symptoms such as confusion, blurred vision, seizures, and loss of consciousness. In such cases, glucagon can be administered to quickly raise the blood glucose level.

Choice C rationale

Administering glucagon when the client is unable to eat during sick days is not a recommended use of a glucagon emergency kit. While it’s true that illness can affect blood glucose levels,

glucagon is specifically used to treat severe hypoglycemia. Other strategies, such as adjusting insulin doses or consuming liquid or soft carbohydrates, are typically recommended when a person with diabetes is sick and unable to eat their usual meals.

Choice D rationale

Administering glucagon at the onset of symptoms of diabetic ketoacidosis is not a recommended use of a glucagon emergency kit. Diabetic ketoacidosis is a serious complication of diabetes that occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic. Glucagon would not be effective in treating this condition.