Nur 215 Medical Surgical 1

Correct Answer:

Obtains relief from muscle spasms

Explanation:

Baclofen is a muscle relaxant prescribed to treat spasticity, a common symptom in multiple sclerosis (MS). The intended effect is to reduce muscle spasms, which improves mobility and comfort. Relief from spasms indicates the drug is working as intended and provides measurable therapeutic benefit in patients with MS.

Why Other Options Are Wrong:

Increased energy

This is not a direct effect of baclofen. In fact, one of its side effects can be drowsiness or sedation.

Absence of a urinary tract infection

Baclofen has no antibacterial properties. It does not treat or prevent UTIs and is unrelated to urinary infection management.

No longer has double vision

Double vision (diplopia) in MS is due to nerve demyelination. Baclofen does not treat visual disturbances—it targets muscle tone and spasticity.

Correct Answer:

Assess level of consciousness

Explanation:

The Glasgow Coma Scale (GCS) is a standardized tool used to assess a patient's level of consciousness after a brain injury or during neurological assessments. It evaluates three key functions: eye opening, verbal response, and motor response, with scores indicating the severity of impaired consciousness. The GCS helps healthcare providers quickly determine the neurological status and monitor for changes. It is especially critical in trauma, ICU, and stroke settings where level of consciousness is essential to treatment decisions.

Why Other Options Are Wrong:

Assess pupillary response

This is incorrect because the GCS does not assess pupil size or reactivity. Pupillary response is typically evaluated separately during a full neurological exam and involves checking for changes in size, shape, and light reflex.

Test muscle strength

This is inaccurate. While the motor response is part of the GCS, it does not specifically measure strength but rather the patient's ability to respond to stimuli. Muscle strength is assessed using separate grading systems like the Manual Muscle Testing scale.

Determine memory loss

This is incorrect. Memory assessment involves cognitive tests, such as asking the patient to recall information or events. The GCS does not include components that evaluate short- or long-term memory function.

Correct Answer:

Teach female patients to wipe from front to back after urinating

Explanation:

Wiping from front to back is a key hygienic practice to prevent bacterial contamination of the urinary tract, especially in females due to the proximity of the urethra to the anus. This method reduces the risk of transferring fecal bacteria such as E. coli into the urethra, which is a common cause of urinary tract infections. It is a simple and highly effective preventive measure that should be routinely taught during patient education. Promoting proper perineal hygiene can significantly decrease UTI incidence.

Why Other Options Are Wrong:

Encourage patients to drink at least 8 ounces of water every hour

While increasing fluid intake can help flush the urinary system, drinking 8 ounces every hour is excessive and unrealistic for most patients. Overhydration can lead to complications, especially in those with heart or kidney issues. Proper hydration should be tailored to individual needs.

Instruct patients to use bath powder to absorb perineal perspiration

Bath powder may help with moisture but does not address bacterial contamination or reduce UTI risk. In some cases, powders can even irritate the skin or promote yeast growth if not used appropriately.

Advise patients to hold urine as long as possible

Holding urine for extended periods increases the risk of urinary stasis and bacterial growth, leading to infection. Encouraging timely voiding is a more appropriate strategy to prevent UTIs.

Correct Answer:

“I can stop using the medication if my skin looks worse.”

Explanation:

Fluorouracil often causes the skin to look worse before it gets better. Redness, scaling, and inflammation are expected effects of the medication as it destroys precancerous or cancerous cells. Stopping the medication early due to worsening appearance would reduce its effectiveness. Patients need to understand this and complete the prescribed course unless otherwise directed by the healthcare provider.

Why Other Options Are Wrong:

“I need to avoid being in the sun while on this medication.”

This is correct and important. Fluorouracil increases photosensitivity, and sun exposure can worsen irritation and damage.

“I will apply the medication only to the affected areas.”

This is appropriate, as fluorouracil should not be applied to healthy skin. Applying only to the treatment area limits unnecessary irritation.

“I will wash my hands before and after applying the medication.”

This is also correct. It prevents accidental transfer of the medication to other parts of the body or to other individuals.

Correct Answer:

Patient may experience urinary frequency, urgency, and nocturia

Explanation:

With aging, several normal physiological changes occur in the urinary system. Decreased bladder capacity, reduced bladder tone, and weakened sphincter muscles contribute to urinary frequency, urgency, and nocturia. These changes are not necessarily signs of disease but are common in the older adult population. Educating patients on these expected changes helps set realistic expectations and promotes early detection of abnormal patterns.

Why Other Options Are Wrong:

Kidneys are able to concentrate urine

This is incorrect because aging kidneys actually have a reduced ability to concentrate urine. This can contribute to dehydration and electrolyte imbalance in older adults.

Kidney is easily palpated

Normally, the kidneys are not easily palpated unless they are enlarged or displaced. In healthy aging, this is not an expected finding and may indicate pathology.

Patient will eventually require wearing a brief at all times

This is an overgeneralization. While incontinence may increase with age, not all elderly individuals require briefs, and many manage urinary function independently or with minimal support.

Correct Answer:

Lateral recumbent with chin resting on flexed knees

Explanation:

The lateral recumbent position with the patient’s back arched and chin resting on flexed knees allows maximum separation of the vertebrae. This positioning facilitates access to the subarachnoid space for the lumbar puncture. It also helps the patient remain still during the procedure, reducing the risk of needle misplacement. Correct positioning is essential to ensure safety and obtain accurate cerebrospinal fluid (CSF) samples.

Why Other Options Are Wrong:

Prone with the head turned to the right

The prone position does not adequately separate the vertebrae and is not standard for lumbar puncture. It also makes needle placement more difficult and less controlled.

Supine with the knees raised toward the chest

This position does not offer the same degree of spinal flexion as the lateral recumbent position. It is not ideal for accessing the lumbar subarachnoid space.

Prone with right leg flexed

Again, the prone position is incorrect for this procedure, and flexing just one leg does not aid spinal access. This posture may actually increase patient discomfort without benefit.

Correct Answer:

Respiratory infection

Explanation:

A myasthenic crisis is a severe exacerbation of myasthenia gravis characterized by muscle weakness that can affect breathing and swallowing. Respiratory infections are one of the most common triggers for these crises because they increase metabolic demand and stress the neuromuscular system. Infection can impair respiratory muscle function and precipitate respiratory failure, requiring immediate intervention such as ventilatory support.

Why Other Options Are Wrong:

Diet high in protein

Dietary protein intake does not trigger a myasthenic crisis. Nutritional management is important, but it is not a causative factor in crisis episodes.

Taking too much medication

Overmedication can lead to a cholinergic crisis, not a myasthenic crisis. The two are different conditions with overlapping symptoms but different causes and treatments.

Orthostatic hypotension

This is a cardiovascular issue unrelated to neuromuscular junction disorders like myasthenia gravis. It does not trigger myasthenic crisis and is not commonly associated with it.

Correct Answer:

Receive an annual influenza vaccination

Explanation:

Preventing infections is a critical part of managing myasthenia gravis because illnesses such as the flu can trigger a myasthenic crisis—a life-threatening exacerbation of muscle weakness. An annual influenza vaccination helps protect patients from respiratory infections that may compromise respiratory muscles already weakened by the disease. Vaccination is a proactive step to reduce the risk of systemic illness and serious complications. It is a key aspect of long-term disease management.

Why Other Options Are Wrong:

Wear gloves when handling frozen food items

This may help with conditions like Raynaud’s phenomenon, but it has no direct impact on preventing myasthenic crisis. It is unrelated to infection control or neuromuscular health in this context.

Avoid warm climates

While heat may cause discomfort or fatigue in some patients with neurological conditions, avoiding warm climates is not a primary or evidence-based intervention to prevent myasthenic crisis.

Increase intake of protein

Protein is important for general health but is not specifically linked to preventing myasthenic crisis. The focus should be on avoiding infection and managing medications, not adjusting macronutrient intake unless prescribed for another reason.

Correct Answer:

Strike a flat hand covering the costovertebral angle (CVA)

Explanation:

Assessment for costovertebral angle (CVA) tenderness is a standard method for evaluating flank pain, often associated with kidney infection such as pyelonephritis. The nurse places one hand flat over the CVA region and strikes it with the fist of the other hand. A positive response is pain or discomfort, indicating possible inflammation or infection in the kidney. This is a quick, non-invasive method to support diagnostic decisions.

Why Other Options Are Wrong:

Palpate along both sides of the lumbar vertebral column

Palpation can assess muscle or skeletal tenderness but is not specific or reliable for evaluating kidney inflammation or infection.

Push fingers upward into the two lowest intercostal spaces

This technique is not relevant to kidney assessment. It may be used in abdominal exams but does not target the CVA where the kidneys are located.

Percuss between the iliac crest and ribs at the midaxillary line

Although this area may be near the CVA, this technique does not accurately localize kidney tenderness and is not the standard method for assessing flank pain related to pyelonephritis.