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:

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:

Topical corticosteroid

Explanation:

Contact dermatitis is a localized inflammatory skin condition typically caused by an irritant or allergen. The standard treatment is a topical corticosteroid, which helps reduce redness, swelling, and itching by suppressing the inflammatory response in the skin. It is applied directly to the affected area and is usually effective in mild to moderate cases. Systemic treatment is generally reserved for severe or widespread reactions.

Why Other Options Are Wrong:

Intravenous corticosteroid

This is not commonly used for contact dermatitis unless the condition is severe and widespread. Systemic corticosteroids are generally a second-line treatment.

Intravenous antibiotic

Contact dermatitis is not an infectious condition, so antibiotics are not appropriate unless there is secondary infection, which is not the first-line concern.

Oral antibiotic

Similarly, oral antibiotics are not needed unless there is a superimposed bacterial infection. The primary treatment focuses on reducing inflammation, not eliminating bacteria.

Correct Answer:

Gastrointestinal tract

Explanation:

Escherichia coli (E. coli) is a gram-negative bacillus that is normally found in the gastrointestinal (GI) tract. It can migrate from the GI tract to the urinary tract, often due to poor hygiene or improper wiping technique, especially in females. Once in the urinary tract, it can colonize and cause infections such as cystitis or pyelonephritis. The GI tract is the primary reservoir for E. coli, making it the most likely source of transmission.

Why Other Options Are Wrong:

Genitourinary tract

While the infection occurs in the urinary tract, the source of E. coli is the gastrointestinal tract. The urinary tract is the site of infection, not the origin of the bacteria.

Integumentary tract

The skin (integumentary system) is not a common source of E. coli. This system is more often associated with pathogens like Staphylococcus aureus.

Nasopharyngeal tract

This area is typically associated with respiratory pathogens, not E. coli. It plays no role in typical urinary tract infections.

Correct Answer:

The nurse separates the patient’s labia with the dominant hand.

Explanation:

During urinary catheterization, the non-dominant hand is used to separate the labia and maintain exposure of the urethral meatus. This hand is considered contaminated once it touches the patient and must remain in place. The dominant hand is used for the sterile procedure, including insertion of the catheter. Using the dominant hand to separate the labia compromises sterile technique and increases the risk of introducing infection. This is a key point where the charge nurse must intervene to maintain aseptic technique.

Why Other Options Are Wrong:

The nurse provides perineal care prior to inserting the urinary catheter.

This is correct practice. Cleaning the perineal area before catheter insertion helps minimize the risk of introducing bacteria into the urinary tract, reducing the chance of catheter-associated infections.

The nurse applies the sterile drape prior to inserting the urinary catheter.

This is standard and expected practice. Draping the area with sterile material helps establish a sterile field and maintain aseptic technique throughout the procedure.

The nurse coats the indwelling urinary catheter tip with lubricant.

Lubricating the catheter tip is essential to ease insertion and reduce patient discomfort or injury. This is a necessary and proper step in the procedure.

Correct Answer:

Keep active, use stress-reduction strategies and avoid fatigue

Explanation:

Even for patients on bed rest, encouraging as much activity as tolerated helps reduce complications like muscle atrophy, pressure injuries, and respiratory issues. For patients with an indwelling catheter, stress and fatigue can also impair immune function and recovery. Stress-reduction and energy conservation strategies are essential to preserve physical and mental well-being during limited mobility. Maintaining a positive, proactive approach to care supports recovery.

Why Other Options Are Wrong:

Follow good health habits to change the course of the disease

This does not directly address the immediate nursing concern for a patient with a catheter and on bed rest. It is vague and not a priority intervention.

Practice using the mechanical aids that you will need with future disabilities arise

This statement assumes future decline and is not patient-centered or timely. The focus should be on current needs and abilities.

You will need to accept the necessity of a quiet and inactive lifestyle

This promotes passivity and can worsen physical deconditioning. Bed rest should be managed with interventions that promote safe mobility and prevent complications.

Correct Answer:

Hesitancy

Nocturia

Dysuria

Incomplete emptying

Hematuria

Explanation:

Lower urinary tract infection (UTI) typically presents with localized symptoms related to bladder irritation and incomplete bladder emptying. These include dysuria (painful urination), hesitancy (difficulty starting urination), nocturia (frequent urination at night), incomplete emptying, and sometimes hematuria (blood in the urine). These symptoms result from inflammation of the bladder and urethra due to bacterial invasion, most commonly by E. coli.

Why Other Options Are Wrong:

Fever

Fever is more common in upper UTIs (such as pyelonephritis). Lower UTIs may not cause systemic signs like fever unless they progress.

Chills

Chills are also typically associated with systemic infection or upper urinary tract involvement. They are not hallmark signs of lower UTI alone.

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:

“Keep active, use stress-reduction strategies and avoid fatigue.”

Explanation:

Patients with multiple sclerosis (MS) benefit from staying active within their tolerance level and avoiding overexertion, which can trigger exacerbations. Stress management and energy conservation are important parts of maintaining function and quality of life. This teaching encourages proactive management of symptoms while emphasizing rest as needed to prevent fatigue, a common symptom in MS. Balancing activity with rest is key to optimal long-term function.

Why Other Options Are Wrong:

“Follow good health habits to change the course of the disease.”

While healthy habits are always encouraged, MS is a progressive autoimmune disorder, and no lifestyle change has been shown to alter its course significantly. This statement could give false hope about disease modification.

“Practice using the mechanical aids that you will need with future disabilities arise.”

It is not appropriate to assume the patient will inevitably need mechanical aids. MS progression is variable, and assistive devices should be introduced based on current, not assumed, needs.

“You will need to accept the necessity of a quiet and inactive lifestyle.”

This is not therapeutic advice. Inactivity can lead to further deconditioning and depression. Patients are encouraged to remain as active and engaged as possible.