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:

Drooping eye lids

Explanation:

Ptosis, or drooping eyelids, is a hallmark symptom of myasthenia gravis due to the autoimmune destruction of acetylcholine receptors, leading to skeletal muscle weakness. Ocular symptoms such as ptosis and diplopia often appear first, especially after sustained muscle use. The weakness worsens with activity and improves with rest, which is characteristic of this disease. Recognizing early signs like ptosis is crucial for diagnosis and timely management.

Why Other Options Are Wrong:

Peripheral edema

This is not associated with myasthenia gravis. Edema is more common in conditions related to fluid imbalance, heart failure, or kidney dysfunction.

Loss of cognitive function

Myasthenia gravis affects motor neurons, not cognitive processing. Patients typically maintain normal mental status unless affected by unrelated conditions or medication side effects.

Fluctuations in heart rate

While autonomic symptoms can occur in some advanced neuromuscular disorders, they are not a common feature of myasthenia gravis. Heart rate variability is not expected in routine cases.

Correct Answer:

Mobility

Nutrition

Sensory perception

Moisture

Explanation:

The Braden Scale is a validated tool used to assess a patient's risk for developing pressure injuries. It includes six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. These categories help evaluate the patient’s functional ability and skin integrity risk. Mobility, nutrition, sensory perception, and moisture are all core components that directly influence skin health and pressure injury risk.

Why Other Options Are Wrong:

Pain

Pain is not one of the official subscales of the Braden Scale. Although pain may influence a patient's activity or behavior, it is not scored directly within this risk assessment tool.

Correct Answer:

“Monitor for tendon pain.”

Explanation:

Ciprofloxacin, a fluoroquinolone antibiotic, carries a black box warning for tendonitis and tendon rupture, particularly in older adults and those on corticosteroids. Patients should be instructed to report any new tendon pain, swelling, or inflammation, especially in the Achilles tendon. Early recognition and discontinuation of the drug can prevent further injury. Monitoring for musculoskeletal symptoms is a vital part of ciprofloxacin safety education.

Why Other Options Are Wrong:

“Take this medication with an antacid.”

This is incorrect because antacids containing magnesium or aluminum can interfere with ciprofloxacin absorption. Patients should be instructed to separate ciprofloxacin from antacids by several hours.

“Limit fluid intake while on this medication.”

Fluids should not be restricted while taking ciprofloxacin. In fact, maintaining adequate hydration is encouraged to prevent crystalluria and support renal function.

“Expect urine to turn dark orange.”

This is an expected side effect of phenazopyridine (Pyridium), not ciprofloxacin. Ciprofloxacin does not typically discolor urine, so this would be misleading.

Correct Answer:

Electroencephalography (EEG)

Explanation:

An EEG (electroencephalogram) is the most appropriate diagnostic test for evaluating seizure disorders. It measures electrical activity in the brain and can identify abnormal patterns suggestive of epilepsy or other seizure conditions. The EEG helps determine the type and origin of seizures, aiding in diagnosis and treatment planning. It is noninvasive, commonly used, and essential for neurologic assessment in suspected seizure disorders.

Why Other Options Are Wrong:

Cerebral angiography

This imaging technique visualizes blood vessels in the brain and is more appropriate for detecting aneurysms or vascular malformations. It is not typically used to diagnose seizures.

Electromyography (EMG)

EMG assesses muscle and nerve function and is useful for conditions like neuropathy or myopathy. It does not evaluate brain activity and is unrelated to seizure assessment.

Lumbar puncture

A lumbar puncture may be used if infection (like meningitis) is suspected, but it is not the primary test for seizure disorders. It helps rule out CNS infections rather than identify seizure activity.

Correct Answer:

The patient wears a watch and wedding band

Explanation:

MRI uses powerful magnets, and any metallic object can pose serious safety risks, including burns, dislodgement, or interference with imaging. Wearing metal items like a watch or wedding band is contraindicated because these objects can become projectiles or heat up during the scan. The patient must be screened and instructed to remove all metal before the procedure. Ensuring the patient is metal-free protects both the individual and the integrity of the imaging process.

Why Other Options Are Wrong:

The patient receives lorazepam 1 mg by mouth prior to the procedure

Lorazepam may be given to relieve anxiety, especially for patients who are claustrophobic. It does not interfere with the MRI procedure and can actually improve patient cooperation.

The patient eats breakfast prior to the procedure

MRI scans typically do not require fasting unless contrast agents or sedation are involved. Eating a light meal is generally acceptable and does not pose a threat.

The patient is positioned supine

Lying supine is the standard position for most MRI procedures. This positioning supports proper alignment and stillness during the scan and is not a safety concern.

Correct Answer:

It does not alter the underlying disease process, but it may improve a client’s quality of life

Explanation:

Carbidopa/levodopa is a cornerstone medication for managing the symptoms of Parkinson’s disease. It does not modify or reverse the disease itself, as Parkinson’s is a progressive neurodegenerative disorder. Instead, the medication helps restore dopamine balance in the brain, which can significantly reduce motor symptoms such as tremors, stiffness, and slowness of movement. By relieving symptoms, it can greatly enhance the patient's quality of life even though the disease continues to progress.

Why Other Options Are Wrong:

It will send the disease into remission and eventually cure the disease

This is inaccurate because Parkinson’s disease is chronic and progressive. There is currently no known cure or remission phase for the disease, and medications only manage symptoms. This option creates a false sense of expectation about treatment outcomes.

It will control the symptoms for 10 to 12 years

While carbidopa/levodopa is initially effective, its long-term use is often associated with diminishing returns and complications like motor fluctuations and dyskinesias. The specific duration of symptom control varies and is not guaranteed for 10–12 years.

It is the treatment of last resort and may control symptoms

Carbidopa/levodopa is actually considered first-line therapy in many cases, especially when symptoms significantly impair functioning. Labeling it as a “treatment of last resort” is misleading and clinically incorrect.

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:

Decrease in elasticity on skin turgor is a normal part of aging

Explanation:

As people age, their skin loses collagen and elastin, leading to decreased skin elasticity. This normal aging process affects the reliability of skin turgor assessment as a measure of hydration. The nurse must understand that reduced skin turgor in older adults does not necessarily indicate dehydration, especially if assessed on the back of the hand. Instead, the clavicle or sternum area may give a more accurate picture. Recognizing these physiological changes helps prevent misinterpretation during assessment.

Why Other Options Are Wrong:

Older adults skin turgor is moist and boggy

This is inaccurate. Normal skin turgor in older adults is not described as moist or boggy. “Boggy” often refers to tissue swelling or infection, and moisture level does not define turgor. This description mischaracterizes normal aging changes in skin.

Skin turgor is unaffected by aging

This is incorrect because aging significantly affects skin elasticity. With age, the dermis thins and connective tissue breaks down, which reduces skin's ability to return to its normal shape quickly. This makes turgor assessments less reliable if not adjusted for age-related changes.

Assessment should only be performed on the hands of the older adults

This is false. In older adults, hand skin turgor is not reliable due to loss of subcutaneous tissue. Nurses should assess skin turgor over areas such as the sternum or forehead for a more accurate hydration status in older adults.