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

Advise the patient to move slowly and cautiously when getting up and walking.

Evaluate the patient’s muscle strength every 4 hours.

Monitor the patient’s intake and output every 8 hours.

Ensure the patient understands to stop taking baclofen before using other antispasmodics.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Baclofen is a muscle relaxant used to treat muscle symptoms caused by multiple sclerosis (MS), including spasm, pain, and stiffness. It acts on the central nervous system to relieve spasticity, improving muscle movement and relieving pain from spasticity. One of the common side effects of Baclofen is drowsiness, dizziness, and weakness. Therefore, advising the patient to move slowly and cautiously when getting up and walking is an important nursing intervention to prevent falls and injuries.

Choice B rationale

While evaluating the patient’s muscle strength every 4 hours can provide valuable information about the patient’s response to treatment, it is not the most critical intervention in this context. Baclofen’s primary effect is to relieve spasticity, not necessarily to increase muscle strength.

Choice C rationale

Monitoring the patient’s intake and output every 8 hours is a standard nursing intervention for many patients, but it is not specifically related to the administration of baclofen.

Choice D rationale

While it’s important for patients to understand their medication regimen, including when to stop taking certain medications, baclofen should not be stopped abruptly. Abrupt discontinuation has resulted in serious adverse reactions including death. Therefore, ensuring the patient understands to stop taking baclofen before using other antispasmodics is not the correct intervention.

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Correct Answer is A

Explanation

Choice A rationale

Filgrastim is a medication used to stimulate the growth of white blood cells, making patients less vulnerable to infections. If the patient’s white blood cell count has increased from 2,500/mm^3 to 5,000/mm^3 after administering five doses of filgrastim, it indicates that the medication has been effective.

Choice B rationale

Reviewing the patient’s culture and sensitivity reports is not directly related to the effect of filgrastim on white blood cell count.

Choice C rationale

Neutropenic precautions are typically implemented when a patient has a low white blood cell count. Since the patient’s white blood cell count has increased, implementing neutropenic precautions may not be necessary.

Choice D rationale

While it’s always important to monitor a patient’s vital signs, there’s no specific reason to do so just because the patient’s white blood cell count has increased after administering filgrastim.

A. Instruct the patient to exhale rapidly into the mouthpiece when using the discus. B. Explain that the patient should not use the discus more than twice daily. C. Inform that patients using the discus may experience a decrease in blood pressure. D. Suggest offering the discus to the patient for use during an acute asthma attack.

Correct Answer is B

Explanation

Choice A rationale

Instructing the patient to exhale rapidly into the mouthpiece when using the discus is incorrect. The patient should breathe in through their mouth as deeply as they can until they have taken a full deep breath.

Choice B rationale

Fluticasone and salmeterol is a combination of two medicines that are used to help control the symptoms of asthma and improve breathing. It is used when a patient’s asthma has not been controlled sufficiently on other asthma medicines, or when a patient’s condition is so severe that more than one medicine is needed every day. Therefore, explaining that the patient should not use the discus more than twice daily is the correct instruction.

Choice C rationale

Informing that patients using the discus may experience a decrease in blood pressure is incorrect. The most common side effects of fluticasone and salmeterol include drowsiness, dizziness, and weakness.

Choice D rationale

Suggesting offering the discus to the patient for use during an acute asthma attack is incorrect. Fluticasone and salmeterol is not used to relieve an asthma attack that has already started.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After administering five doses of filgrastim, the nurse observes that the patient’s white blood cell count has increased from 2,500/mm^3 to 5,000/mm^3.What action should the nurse take?

Correct Answer is A

Explanation

A patient in a residential treatment facility uses a fluticasone propionate and salmeterol discus inhalation system to manage asthma.This system delivers an inhaled powdered form of these combined medications. What instruction should the nurse provide to this patient’s caregivers?

Correct Answer is B

Explanation

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