a child is prescribed baclofen lioresal via intrathecal pump to treat severe muscle spasms related to cerebral palsy what teaching does the nurse pro

NCLEX-RN

NCLEX RN Prioritization Questions

1. A child is prescribed baclofen (Lioresal) via intrathecal pump to treat severe muscle spasms related to cerebral palsy. What teaching does the nurse provide the child and parents?

A. Do not let this prescription run out.
B. The medication may cause gingival hyperplasia.
C. Periodic serum drug levels are needed.
D. Watch for excessive facial hair growth.

Correct answer: A

Rationale: The correct teaching for the child and parents when a child is prescribed baclofen via an intrathecal pump is to not let the prescription run out. Abrupt discontinuation of intrathecal baclofen can lead to severe effects like high fever, altered mental status, and rebound spasticity and muscle rigidity. It is crucial for the parents to ensure there is always an adequate supply of this medication to prevent these adverse effects. Choices B and D are incorrect because gingival hyperplasia and hirsutism are side effects associated with phenytoin (Dilantin), not baclofen. Choice C is incorrect as serum drug levels are not typically monitored for intrathecal medications.

2. The health care provider writes an order for bacteriologic testing for a patient who has a positive tuberculosis skin test. Which action should the nurse take?

A. Teach about the reason for the blood tests.
B. Schedule an appointment for a chest x-ray.
C. Teach about the need to get sputum specimens for 2 to 3 consecutive days.
D. Instruct the patient to expectorate three specimens as soon as possible.

Correct answer: C

Rationale: The correct action for the nurse to take is to teach the patient about the need to collect sputum specimens for 2 to 3 consecutive days for bacteriologic testing for M. tuberculosis. It is important to obtain these specimens on different days rather than all at once. Blood tests are not used for tuberculosis testing, so teaching about blood tests is not relevant. While a chest x-ray is important in tuberculosis diagnosis, it is not a bacteriologic test. The appearance on a chest x-ray alone is not sufficient to diagnose TB as other diseases can have similar findings.

3. While receiving normal saline infusions to treat a GI bleed, the nurse notes that the patient's lower legs have become edematous and auscultates crackles in the lungs. What should the nurse do first?

A. Stop the saline infusion immediately
B. Notify the physician
C. Elevate the patient's legs
D. Continue the infusion, as these findings are normal

Correct answer: A

Rationale: The correct answer is to stop the saline infusion immediately. The patient is showing signs of fluid volume overload due to rapid fluid replacement, indicated by lower leg edema and lung crackles. Continuing the infusion could worsen the overload and potentially lead to complications. Notifying the physician is important but should come after stopping the infusion to address the immediate issue. Elevating the patient's legs may help with edema but is not the priority in this situation. Continuing the infusion when the patient is already showing signs of fluid overload is contraindicated and can be harmful.

4. Why are subdural hemorrhages more common in the elderly?

A. Increased anticoagulant use
B. Increased risk of falls
C. Brain atrophy
D. Inconsistent care giving

Correct answer: C

Rationale: Subdural hemorrhages are more common in the elderly due to cerebral atrophy resulting from the natural aging process. This atrophy can lead to the stretching of bridging veins, making them more fragile and prone to tearing even with minor trauma. While increased anticoagulant use and a higher risk of falls are common in the elderly, brain atrophy plays a more direct role in the increased incidence of subdural hemorrhages. Inconsistent caregiving, on the other hand, is not a direct cause of subdural hemorrhages but may impact the overall management and outcome of such cases.

5. Which individual is at greatest risk for developing hypertension?

A. 45-year-old African-American attorney
B. 60-year-old Asian-American shop owner
C. 40-year-old Caucasian nurse
D. 55-year-old Hispanic teacher

Correct answer: A

Rationale: African-Americans have a higher risk of developing hypertension compared to other ethnic groups. They tend to develop high blood pressure at younger ages and are more sensitive to salt, which increases their risk of hypertension. Additionally, studies have shown that African-Americans may respond differently to hypertensive drugs. Therefore, the 45-year-old African-American attorney is at the greatest risk for developing hypertension. The other choices do not specify factors that put them at a higher risk for hypertension compared to African-Americans.