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

Evaluate muscle strength every 4 hours.

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

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

Monitor intake and output every 8 hours.

Answer and Explanation

The Correct Answer is B

A. Evaluate muscle strength every 4 hours: While assessing muscle strength is important in clients with multiple sclerosis, it does not need to be done this frequently unless the client is unstable. Baclofen may cause weakness, but routine assessments every 4 hours are excessive for stable patients.

B. Advise the client to move slowly and cautiously when rising and walking: Baclofen can cause dizziness, sedation, decreased muscle tone and orthostatic hypotension, particularly in the early stages of treatment. Educating the client to change positions carefully helps reduce the risk of falls and injury.

C. Ensure the client knows to stop baclofen before using other antispasmodics: Baclofen should not be stopped abruptly due to the risk of withdrawal symptoms like hallucinations or seizures. Combining different antispasmodic medications can increase the risk of adverse effects such as excessive sedation or muscle weakness. Medication changes therefore should only be made under the supervision of the healthcare provider.

D. Monitor intake and output every 8 hours: Baclofen does not typically affect renal function or fluid balance significantly. Monitoring intake and output is not a standard intervention specific to baclofen administration unless there is another underlying condition.

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Correct Answer is A

Explanation

A. Serum liver enzymes: Statins are metabolized in the liver and can cause hepatotoxicity. Baseline liver enzyme levels, such as ALT and AST, should be reviewed before starting statin therapy to ensure the liver is functioning properly and to monitor for potential adverse effects.

B. Serum electrolytes: Electrolytes are important for overall health, but they are not specifically impacted by statin therapy. Reviewing electrolyte levels is not a priority before initiating statins unless other conditions warrant it.

C. Complete blood count: A complete blood count (CBC) provides valuable information about infection or anemia, but it is not directly related to the safety or monitoring of statin medications.

D. Capillary blood glucose: Statins have been associated with a slight risk of elevated blood glucose over long-term use, but an initial capillary blood glucose reading is not required prior to starting therapy. Liver function assessment is the priority.

A. Excessive bruising. B. Muscle tenderness.. C. Nausea and vomiting. D. Peripheral edema.

Correct Answer is B

Explanation

A. Excessive bruising: While statins can rarely affect platelet function, leading to bruising, this is not commonly associated with elevated creatine kinase (CK) levels. Bruising is more indicative of coagulation issues rather than muscle injury.

B. Muscle tenderness: Elevated CK levels in a client taking atorvastatin suggest muscle injury, such as myopathy or rhabdomyolysis. Muscle tenderness, pain, or weakness are hallmark symptoms of these conditions. Prompt assessment is crucial, as continued statin use in the presence of muscle damage can lead to serious complications, including kidney failure .

C. Nausea and vomiting: These symptoms are nonspecific and can result from various causes. While they may occur in rhabdomyolysis, they are not primary indicators and should be considered in the broader clinical context.

D. Peripheral edema: Swelling in the extremities is not a typical sign of statin-induced muscle injury. It is more commonly associated with cardiac, renal, or hepatic conditions.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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