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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Choice A rationale
Crushing and mixing ciprofloxacin hydrochloride tablets with pudding is not recommended. Ciprofloxacin is an antibiotic used to treat a variety of bacterial infections, including anthrax. It should be taken as directed by a healthcare provider, usually every 12 hours with a full glass of
water. Crushing the tablets can lead to a sudden release of the drug, causing side effects or an overdose.
Choice B rationale
Increasing fluid intake while taking the medication is advisable. Ciprofloxacin can cause crystalluria, which are crystals in the urine, in some patients. Drinking plenty of fluids while taking this medication helps to prevent the formation of these crystals.
Choice C rationale
Using nonsteroidal anti-inflammatory drugs (NSAIDs) to relieve mild joint aches and pains caused by the medication is not recommended. Ciprofloxacin can increase the effects of certain medications, including NSAIDs, leading to an increased risk of side effects such as gastrointestinal bleeding.
Choice D rationale
Reporting any tendon pain or swelling to the healthcare provider immediately is crucial. Ciprofloxacin has been associated with an increased risk of tendonitis and tendon rupture, particularly in older adults and those taking corticosteroids.
Choice E rationale
Limiting exposure to sunlight and avoiding tanning beds is important. Ciprofloxacin can make the skin more sensitive to sunlight, increasing the risk of sunburn. Patients should wear protective clothing and use sunscreen when outdoors.
Correct Answer is C
Explanation
Choice A rationale
Administering a narcotic reversal drug is not the first action the nurse should take. While it’s true that the client’s symptoms could be due to opioid overdose, the nurse should first confirm the cause of the symptoms. In this case, the nurse finds four patches on the client’s body, which is unusual and could lead to an overdose. Therefore, the first action should be to remove the patches to prevent further absorption of the drug.
Choice B rationale
Applying an oxygen face mask might be necessary if the client is having difficulty breathing. However, this would not address the underlying problem if the client is experiencing an overdose from the morphine sulfate patches. The nurse should first remove the patches to stop further drug absorption.
Choice C rationale
The nurse finds four patches on the client’s body. This is unusual and could lead to an overdose. Therefore, the nurse’s first action should be to remove the patches to prevent further absorption of the drug. After removing the patches, the nurse can assess the client’s condition and provide further interventions as needed.
Choice D rationale
Monitoring the client’s blood pressure is an important nursing intervention, but it should not be the first action in this situation. The nurse has already found a potential cause for the client’s symptoms (i.e., the four morphine sulfate patches). Therefore, the first action should be to address this problem by removing the patches.
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