chapter 64 ~ Management of Patients with Neurologic Infections, Autoimmune Disorders, and Neuropathies

The nurse is caring for a client admitted with a diagnosis of septic meningitis. The nurse is aware that this infection is caused by which of the following?

Bacteria rationale: Septic meningitis is caused by bacteria. In aseptic meningitis, the cause is viral or secondary to lymphoma, leukemia, or human immunodeficiency virus.

A nurse is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the care plan?

Develop a written, individual turning schedule. rationale: A turning schedule sheet helps ensure that the client gets turned and, thus, helps prevent pressure ulcers. Turning should occur every 1 to 2 hours — not every 8 hours — for clients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist but should avoid vigorous massage, which could damage capillaries. When moving the client, the nurse should lift — rather than slide — the client to avoid shearing.

An older adult experienced a cerebrovascular disease 6 weeks ago and is currently receiving inpatient rehabilitation. The nurse is coaching the client to contract and relax her muscles while keeping her extremity in a fixed position. Which type of exercise is the client performing?

Isometric rationale: Isometric exercises are those in which there is alternating contraction and relaxation of a muscle while keeping the part in a fixed position. This exercise is performed by the client. Passive exercises are carried out by the therapist or the nurse without assistance from the client. Resistive exercises are carried out by the client working against resistance produced by either manual or mechanical means. Abduction is movement of a part away from the midline of the body.

The diagnosis of multiple sclerosis is based on which test?

Magnetic resonance imaging (MRI) rationale: The diagnosis of MS is based on the presence of multiple plaques in the central nervous system observed on MRI. Electrophoresis of CSF identifies the presence of oligoclonal banding. Evoked potential studies can help define the extent of the disease process and monitor changes. Neuropsychological testing may be indicated to assess cognitive impairment.

The most common cause of cholinergic crisis includes which of the following?

Overmedication rationale: A cholinergic crisis, which is essentially a problem of overmedication, results in severe generalized muscle weakness, respiratory impairment, and excessive pulmonary secretion that may result in respiratory failure. Myasthenic crisis is a sudden, temporary exacerbation of MG symptoms. A common precipitating event for myasthenic crisis is infection. It can result from undermedication.

When developing a plan of care for a patient with impaired physical mobility who must remain on complete bedrest, which of the following would the nurse most likely include to prevent external rotation of the hip?

Trochanter roll rationale: A trochanter roll extending from the crest of the ilium to the mid-thigh prevents external rotation of the hip. Range-of-motion exercises are used to maintain muscle strength and joint mobility. Protective boots are used to prevent foot drop. Using a pillow between the legs would help support the body in the correct alignment.

The nurse has been educating a client newly diagnosed with MS. Which statement by the client indicates an understanding of the education?

"I will stretch daily as directed by the physical therapist." rationale: A stretching routine should be established. Stretching can help prevent contractures and muscle spasticity. Hot baths are discouraged because of the risk of injury. Clients have sensory loss that may contribute to the risk of burns. In addition, hot temperatures may cause an increase in symptoms. Warm packs should be encouraged to provide relief. Progressive weight-bearing exercises are effective in managing muscle spasms. Clients should not hurry through the exercise activity because it may increase muscle spasticity.

A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?

"The paralysis caused by this disease is temporary." rationale: The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs.

The nurse is developing a bowel training program for a patient. What education can the nurse provide for the patient that will increase the chance of success of the bowel program? (Select all that apply.)

- set a daily defecation time that is within 15 minutes of the same time every day. - have an adequate intake of fiber containing foods. - have a fluid intake between 2 and 4 L/day. rationale: Regularity, timing, nutrition (including increased fiber intake), and fluids (2 to 4 L daily), exercise, and correct positioning promote predictable defecation (National Institute for Health and Clinical Excellence, 2010). A regular time for defecation is established, and attempts at evacuation should be made within 15 minutes of the designated time daily. Enemas and laxatives are only needed if the patient is constipated and then only as needed, not daily.

Students are reviewing information about the stages of pressure ulcer development. They demonstrate understanding when they identify which stage as characterized by a full-thickness wound? Select all that apply.

- stage III - stage IV

Myasthenia gravis occurs when antibodies attack which receptor sites?

Acetylcholine rationale: In myasthenia gravis, antibodies directed at the acetylcholine receptor sites impair transmission of impulses across the myoneural junction. Serotonin, dopamine, and gamma-aminobutyric acid are not receptor sites that are attacked in myasthenia gravis.

During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do?

Administer atropine to control the side effects of edrophonium. rationale: Atropine should be available to control the side effects of edrophonium, which include bradycardia, sweating, and cramping.

A client is suspected to have bacterial meningitis. What is the priority nursing intervention?

Administer prescribed antibiotics. rationale: A client with suspected bacterial meningitis should receive antibiotic therapy within 30 minutes of arrival. Outcomes are usually better with early administration of antibiotics. Although the nurse should assess the CSF laboratory test results, antibiotic therapy should not be delayed waiting for the results. Encouraging oral fluids and preparing for a CT scan are appropriate interventions depending on the client, but the priority intervention is the early administration of antibiotics.

A nurse is caring for a client with burns on his legs. Which nursing intervention will help to prevent contractures?

Applying knee splints rationale: Applying knee splints prevents leg contractures by holding the joints in a functional position. Elevating the foot of the bed doesn't prevent contractures. Hyperextending a body part for any length of time is inappropriate; doing so can cause contractures. Performing shoulder ROM exercises can prevent contractures in the shoulders but not in the legs.

Which is the primary medical management of arthropod-borne virus (arboviral) encephalitis?

Controlling seizures and increased intracranial pressure rationale: There is no specific medication for arboviral encephalitis; therefore symptom management is key. Medical management is aimed at controlling seizures and increased intracranial pressure.

A nurse is assessing a client who will be discharged home after rehabilitation for a stroke. The nurse is questioning the client about his instrumental activities of daily living (IADLs). Which of the following would the nurse address?

Cooking rationale: Instrumental activities of daily living (IADLs) include cooking, cleaning, shopping, doing laundry, managing personal finances, developing social and recreational skills, and handling emergencies. Bathing, grooming, and dressing are activities of daily living (ADLs).

Which condition is a rare, transmissible, progressive fatal disease of the central nervous system characterized by spongiform degeneration of the gray matter of the brain?

Creutzfeldt-Jakob disease rationale: Creutzfeldt-Jakob disease causes severe dementia and myoclonus. Multiple sclerosis is a chronic, degenerative, progressive disease of the central nervous system characterized by the occurrence of small patches of demyelination in the brain and spinal cord. Parkinson disease is associated with decreased levels of dopamine due to destruction of pigmented neuronal cells in the substantia nigra in the basal ganglia of the brain. Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary dancelike movements and dementia.

A nurse assesses an older adult's risk for pressure ulcers based on the understanding that which of the following increases the client's susceptibility?

Diminished dermal collagen rationale: Slowed peristaltic activity would be a contributing factor for an older adult's risk for developing constipation. Older adults are more susceptible to pressure ulcers because of diminished epidermal thickness, dermal collagen, and tissue elasticity. The skin is drier due to a decrease in sebaceous and sweat gland activity. Sensory perception also is diminished.

Bell palsy is a disorder of which cranial nerve?

Facial (VII) rationale: Bell palsy is characterized by facial dysfunction, weakness, and paralysis. Trigeminal neuralgia is a disorder of the trigeminal nerve and causes facial pain. Meniere syndrome is a disorder of the vestibulocochlear nerve. Guillain-Barre syndrome is a disorder of the vagus nerve.

A nurse is assessing a patient's level of independent functioning. Which tool would the nurse most frequently use?

Functional Independence Measure rationale: One of the most frequently used tools to assess the patient's level of independence is the Functional Independence Measure (trade marked- FIM), a minimum data set consisting of 18 items. The PULSES profile, Barthel Index, and Patient Evaluation Conference System also are used, but these are more generic measures.

A client with Guillain-Barre syndrome cannot swallow and has a paralytic ileus; the nurse is administering parenteral nutrition intravenously. The nurse is careful to assess which of the following related to intake of nutrients?

Gag reflex and bowel sounds rationale: Paralytic ileus may result from insufficient parasympathetic activity. The nurse may administer parenteral nutrition and IV fluids. The nurse carefully assesses for the return of the gag reflex and bowel sounds before resuming oral nutrition. The other three choices are important assessment items, but not necessarily related to the intake of nutrients.

A client has been brought to the ED with altered LOC, high fever, and a purpura rash on the lower extremities. The family states the client was reporting neck stiffness earlier in the day. What action should the nurse do first?

Initiate isolation precautions. rationale: The signs and symptoms are consistent with bacterial meningitis. The nurse should protect self, other health care workers, and other clients against the spread of the bacteria. Clients should receive the prescribed antibiotics within 30 minutes of arrival, but the nurse can administer the antibiotics after applying the isolation precautions. The nurse can use a cooling blanket to help with the elevated temperature, but this should be done after applying isolation precautions. Prophylaxis antibiotic therapy should be given to people who were in close contact with the patient, but this is not the highest priority nursing intervention.

When describing the role of the various members of the rehabilitation team, which member would the nurse identify as the one who determines the final outcome of the process?

Patient rationale: Although the nurse, physician, and physical therapist play important roles in the rehabilitation process, the patient is a key member of the rehabilitation team, the focus of the team's efforts, and the one who determines the final outcomes of the process.

A client has meningitis and cultures are being done to determine the cause. Which of the following is most likely to be identified as the causative factor?

Streptococcus pneumoniae rationale: The bacteria Streptococcus pneumoniae and Neisseria meningitides are responsible for 80% of cases of meningitis in adults.

During assessment, a patient reports that she sometimes "wets herself" when sneezing. The nurse documents this as which of the following?

Stress incontinence rationale: Stress incontinence occurs when perineal muscles weaken. Urine subsequently leaks when the intra-abdominal pressure increases, such as with sneezing or coughing. Urge incontinence refers to the involuntary elimination of urine associated with a strong perceived need to void. Functional incontinence occurs in patients with intact urinary physiology but who experience mobility impairment, environmental barriers, or cognitive problems and cannot reach and use the toilet before soiling themselves. Reflex or neurogenic incontinence is associated with a spinal cord lesion that interrupts cerebral control, resulting in no sensory awareness of the need to void.

The nurse has developed an evidence-based plan of care for a patient requiring rehabilitation after a total hip replacement. Ultimately, who should approve the plan of care?

The patient rationale: The evidence-based plan of care that nurses develop must be approved by the patient and family and is an integral part of the rehabilitation process.

The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur?

Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes. rationale: Thirty seconds after injection, facial muscle weakness and ptosis should resolve for about 5 minutes (Hickey, 2009). Immediate improvement in muscle strength after administration of this agent represents a positive test and usually confirms the diagnosis.

A client is diagnosed with meningococcal meningitis. The 22-year-old client shares an apartment with one other person. What would the nurse expect as appropriate care for the client's roommate?

Treatment with antimicrobial prophylaxis as soon as possible rationale: People in close contact with clients who have meningococcal meningitis should be treated with antimicrobial chemoprophylaxis, ideally within 24 hours after exposure.

When is the optimal time for the nurse to begin the rehabilitation process for a patient with a cervical spine injury?

With initial patient contact rationale: The principles of rehabilitation are basic to the care of all patients, and rehabilitation efforts should begin during the initial contact with a patient.

A patient has been diagnosed with meningococcal meningitis at a community living home. When should prophylactic therapy begin for those who have had close contact with the patient?

Within 24 hours after exposure rationale: People in close contact with patients with meningococcal meningitis should be treated with antimicrobial chemoprophylaxis using rifampin (Rifadin), ciprofloxacin hydrochloride (Cipro), or ceftriaxone sodium (Rocephin). Therapy should be started within 24 hours after exposure because a delay in the initiation of therapy limits the effectiveness of the prophylaxis.

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to:

rest in an air-conditioned room. rationale: Fatigue is a common symptom in clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, ordered to reduce spasticity, can cause drowsiness and fatigue. Frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy-conservation techniques, and reducing spasticity.

Vagus nerve demyelinization, which may occur in Guillain-Barré syndrome, would not be manifested by which of the following?

20/20 vision rationale: Cranial nerve demyelination can result in a variety of clinical manifestations. Optic nerve demyelination may result in blindness. Bulbar muscle weakness related to demyelination of the glossopharyngeal and vagus nerves results in the inability to swallow or clear secretions. Vagus nerve demyelination results in autonomic dysfunction, manifested by instability of the cardiovascular system. The presentation is variable and may include tachycardia, bradycardia, hypertension, or orthostatic hypotension.

A female client has been achieving significant improvements in her ADLs since beginning rehabilitation after a brain hemorrhage. The nurse must observe and assess the client's ability to perform ADLs to determine the client's level of independence in self-care and her need for nursing intervention. Which of the following additional considerations should the nurse prioritize?

Appraising the family's involvement in the client's ADLs. rationale: The nurse should also be aware of the client's medical conditions or other health problems, the effect that they have on the ability to perform ADLs, and the family's involvement in the client's ADLs. It is not normally necessary to teach the client about the pathophysiology of her functional deficits. A positive attitude is beneficial, but creating this is not normally within the purview of the nurse. The nurse does not liaise with the insurance company.

The nurse is admitting a client into the rehabilitation unit after an industrial accident. The client's nursing diagnoses include disturbed sensory perception and the nurse identifies that he has decreased strength and dexterity. The nurse should know that this client may need what to accomplish self-care?

Appropriate assistive devices rationale: Clients with impaired mobility, sensation, strength, or dexterity may need to use assistive devices to accomplish self-care. An assisted living environment is less common than the use of assistive devices. Family involvement is imperative, but this may or may not take the form of advice. A health care aide is not needed by most clients.

A nurse is assisting with a neurological examination of a client who reports a headache in the occipital area and shows signs of ataxia and nystagmus. Which of the following conditions is the most likely reason for the client's problems?

Cerebellar abscess rationale: Indicators of a cerebellar abscess include occipital headache, ataxia, and nystagmus.

A client is experiencing functional urinary incontinence. The nurse interprets this to mean which of the following?

Client does not reach the toilet before experiencing voiding. rationale: Functional incontinence is incontinence in clients with intact urinary physiology who experience mobility impairment, environmental barriers, or cognitive problems and cannot reach and use the toilet before soiling themselves. Reflex incontinence is associated with a spinal cord lesion that interrupts cerebral control, resulting in no sensory awareness of the need to void. Urge incontinence is the involuntary elimination of urine associated with a strong perceived need to void. Stress incontinence is associated with weakened perineal muscles that permit leakage of urine when intraabdominal pressure is increased, such as with coughing or sneezing.

The nurse is assisting a patient to sit up on the side of the bed in preparation for standing. The patient has been on strict bedrest for more than a week. While assuming the sitting position, the patient begins to report feeling dizzy and nauseated. The patient is pale and diaphoretic. Which of the following would the nurse do next?

Have the patient lie back down. rationale: The patient is exhibiting signs of orthostatic hypotension and cerebral insufficiency from the change in position. The best action would be have the patient lie back down because he or she is not tolerating the change in position. Taking deep breaths would be ineffective in raising the patient's blood pressure or increasing the blood supply to the brain. Having the patient stand up immediately would worsen the patient's symptoms. Using a transfer board would have no effect on the patient's symptoms, which are from the change in position.

A client is experiencing muscle weakness and an ataxic gait. The client has a diagnosis of multiple sclerosis (MS). Based on these symptoms, the nurse formulates "Impaired physical mobility" as one of the nursing diagnoses applicable to the client. What nursing intervention should be most appropriate to address the nursing diagnosis?

Help the client perform range-of-motion (ROM) exercises every 8 hours. rationale: Helping the client perform ROM exercises every 8 hours helps in promoting joint flexibility and muscle tone in a client with muscle weakness. Measures such as using pressure-relieving devices or changing the body positions every 2 hours prevents skin breakdown. The nurse should use a footboard and trochanter rolls to promote a neutral body position that will keep the body in good alignment.

A client spends most of his time in a wheelchair. The nurse would be especially alert for the development of pressure ulcers in which area?

Ischial tuberosity rationale: For a client who sits for prolonged periods, such as in a wheelchair, the ischial tuberosity would be highly susceptible to pressure ulcer development. Areas such as the greater trochanter and lateral malleolus would be susceptible for clients lying on their side. The scapula would be considered a high risk area for clients lying on their back.

Which is the primary vector of arthropod-borne viral encephalitis in North America?

Mosquitoes rationale: The primary vector in North America related to anthropoid-borne virus encephalitis is a mosquito. Birds are associated with the West Nile virus. Spiders and ticks are not vectors for arthropod-borne virus encephalitis.

Which of the following is considered a central nervous system (CNS) disorder?

Multiple sclerosis rationale: Multiple sclerosis is an immune-mediated, progressive demyelinating disease of the CNS. Guillain-Barré, myasthenia gravis, and Bell's palsy are peripheral nervous system disorders.

A client with possible bacterial meningitis is admitted to the ICU. What assessment finding would the nurse expect for a client with this diagnosis?

Neck flexion produces flexion of the knees and hips rationale: Clinical manifestations of bacterial meningitis include a positive Brudzinski sign. Neck flexion producing flexion of knees and hips correlates with a positive Brudzinski sign. Positive Homan sign (pain upon dorsiflexion of the foot) and negative Romberg sign (inability to stand with eyes closed and arms extended) are not expected assessment findings for the client with bacterial meningitis. Peripheral neuropathy manifests as numbness and tingling in the lower extremities. Again, this would not be an initial assessment to rule out bacterial meningitis.

The nurse is assisting a patient in assuming a side-lying position. What intervention would be best for the nurse to provide?

Place the uppermost hip slightly forward in a position of slight abduction. rationale: Supporting the patient in a 30-degree side-lying position avoids pressure on the trochanter. In older adult patients, frequent small shifts of body weight may be effective. Placing a small rolled towel or sheepskin under a shoulder or hip allows a return of blood flow to the skin in the area on which the patient is sitting or lying. The towel or sheepskin is moved around the patient's pressure points in a clockwise fashion. A turning schedule can help the family keep track of the patient's turns.

Which of the following is standard test for early diagnosis of herpes simplex virus (HSV)-1 encephalitis?

Polymerase chain reaction (PCR) rationale: The PCR is the standard test for early diagnosis of HSV-1 encephalitis. The validity of PCR is very high between the third and tenth days after symptom management. Neuroimaging studies, EEG, and CFS examination are used to diagnose HSV encephalitis. Lumbar puncture often reveals a high opening pressure and low glucose and high protein levels in CSF samples.

Which well-recognized sign of meningitis is exhibited when the client's neck is flexed and flexion of the knees and hips is produced?

Positive Brudzinski sign rationale: A positive Brudzinski sign occurs when the client's neck is flexed (after ruling out cervical trauma or injury) and flexion of the knees and hips is produced. Photophobia is sensitivity to light. A positive Kerning sign occurs when the client is lying with the thigh flexed on the abdomen and the leg cannot be completely extended. Nuchal rigidity is neck stiffness.

Which is a component of the nursing management of the client with variant Creutzfeldt-Jakob disease (vCJD)?

Providing palliative care rationale: vCJD is a progressive fatal disease; no treatment is available. Because of the fatal outcome of vCJD, nursing care is primarily supportive and palliative. Prevention of disease transmission is an important part of providing nursing care. Although client isolation is not necessary, use of standard precautions is important. Institutional protocols are followed for blood and body fluid exposure and decontamination of equipment. Organ donation is not an option because of the risk for disease transmission. Amphotericin B is used in the treatment of fungal encephalitis; no treatment is available for vCJD.

A client with herpes simplex virus (HSV) encephalitis is receiving acyclovir. To ensure early intervention, the nurse monitors laboratory values and urine output for which type of adverse reactions?

Renal rationale: Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy. Complications with the integumentary system will can be observed by the nurse; it is not necessary to review laboratory results or urine output for integumentary reactions. Urine output is not monitored for musculoskeletal or hepatic adverse reactions.

Guillain-Barré syndrome is an autoimmune attack on the peripheral myelin sheath. Which of the following is an action of myelin?

Speeds nerve impulse transmission rationale: Myelin is a complex substance that covers nerves, providing insulation and speeding the conduction of impulses from the cell body to the dendrites. The axon carries the message to the next nerve cell. The neuron is the building block of the nervous system. A neurotransmitter is a chemical messenger.

A nurse is performing an admission assessment on a client entering a long-term care facility. She notices a broken area of skin that extends into the dermis on the client's coccyx. How should the nurse document this wound?

Stage II pressure ulcer rationale: A stage II pressure ulcer is a break in the skin that extends into the epidermis or the dermis. A stage I pressure ulcer is area of nonblanchable redness that may become cyanotic. A stage III pressure ulcer extends into the subcutaneous tissue. A stage IV pressure ulcer extends into the muscle or bone; most of the true tissue damage isn't easily seen.

The nurse is assessing a patient's pressure ulcer and notes a full-thickness wound that extends into the subcutaneous tissue. Necrosis and infection are present. The nurse documents this ulcer as which stage?

Stage III rationale: A stage III ulcer is a full-thickness wound that extends into the subcutaneous tissue with necrosis and infection. A stage I ulcer is characterized by an area of erythema that does not blanch with pressure. A stage II ulcer is a partial-thickness wound characterized by a break in the skin with edema and some drainage. A stage IV ulcer is a full-thickness wound that extends to the underlying muscle and bone with deep pockets of infection and necrosis.

A client with respiratory complications of multiple sclerosis (MS) is admitted to the medical-surgical unit. Which equipment is most important for the nurse to keep at the client's bedside?

Suction machine with catheters rationale: MS weakens the respiratory muscles and impairs swallowing, putting the client at risk for aspiration. To ensure a patent oral airway, the nurse should keep a suction machine and suction catheters at the bedside. A sphygmomanometer is no more important for this client than for any other. A padded tongue blade is an appropriate seizure precaution but shouldn't be used in this client because its large size could cause oral airway obstruction. A nasal cannula and oxygen would be ineffective to ensure adequate oxygen delivery; this client requires a mechanical ventilator.

A client has been transferred to a rehabilitative setting from an acute care unit. What is the most important reason for the nurse to begin a program for activities of daily living (ADLs) as soon as the client is admitted to a rehabilitation facility?

The ability to perform ADLs may be the key to re-entering the community. rationale: An ADL program is started as soon as the rehabilitation process begins because the ability to perform ADLs is frequently the key to independence, return to the home, and re-entry into the community. ADLs are frequently the key to independence, not dependence. The ability to perform ADLs is not always a criterion for admission to a group home or assisted-living facility.

The nurse is evaluating the progression of a client in the home setting. Which activity of the hemiplegic client best indicates that the client is assuming independence?

The client grasps the affected arm at the wrist and raises it. rationale: The best evidence that the client is assuming independence is providing range of motions exercises to the affected arm by grasping the arm at the wrist and raising it. The other options require assistance.

Which is the most common cause of acute encephalitis in the United States?

Herpes simplex virus rationale: Viral infection is the most common cause of encephalitis. Herpes simplex virus is the most common cause of acute encephalitis in the United States. The Western equine encephalitis virus, West Nile virus, and St. Louis virus are types of arboviral encephalitis that occur in North America, but they are not the most common causes of acute encephalitis.

A client is receiving baclofen for management of symptoms associated with multiple sclerosis. To evaluate the effectiveness of this medication, what does the nurse assess?

Muscle spasms rationale: Baclofen is a drug used to manage symptoms of muscle spasticity and rigidity in clients diagnosed with neuromuscular disorders. Because of the effects on the CNS, initially, baclofen may cause drowsiness, but sleep is not the intended goal for this therapy. Mood and appetite are not a factor in the administration of this drug.

How can the nurse prevent continuous moisture on the skin of a patient who is at risk for developing skin breakdown?

Practice meticulous hygiene measures. rationale: Continuous moisture on the skin must be prevented by meticulous hygiene measures. It is important to pay special attention to skin folds, including areas under the breasts, arms, and groin, and between the toes. Perspiration, urine, stool, and drainage must be removed from the skin promptly. The soiled skin should be washed immediately with mild soap and water and blotted dry with a soft towel. The skin may be lubricated with a bland lotion to keep it soft and pliable. Drying agents and powders are avoided. Topical barrier ointments (e.g., petroleum jelly) may be helpful in protecting the skin of patients who are incontinent. Placing an indwelling catheter and administering vitamin B12 would not be effective measures in preventing continuous moisture.