Chapter 25 - Muscle Relaxants

11. The nurse assesses a newly admitted patient and finds the muscle tone in his left leg has sustained muscle contraction. How will the nurse document this finding? A) Tonus B) Flaccid C) Atonic D) Spastic

Ans: D Feedback: Muscle spasticity is defined as a sustained muscle contraction. Soft and flabby muscle tone is defined as atonic. A limp muscle without tone is described as flaccid. The state of readiness, known as muscle tone (tonus), is produced by the maintenance of some of the muscle fibers in a contracted state.

21. A patient is admitted to the unit with central spasticity after a terrible motor vehicle accident. The doctor places an intrathecal delivery pump. What medication can be administered via this route to treat the central spasticity? A) Baclofen (Lioresal) B) Cyclobenzaprine (Flexeril) C) Dantrolene (Dantrium) D) Carisoprodol (Soma)

Ans: A Feedback: Baclofen is available in oral and intrathecal forms and can be administered via a delivery pump for the treatment of central spasticity. Flexeril, dantrolene, and Soma are not administered intrathecally.

6. A 20-year-old female patient has been diagnosed with multiple sclerosis. What drug will most likely be prescribed? A) Baclofen (Lioresal) B) Cyclobenzaprine (Flexeril) C) Metaxalone (Skelaxin) D) Orphenadrine (Banflex)

Ans: A Feedback: Baclofen is used for treatment of muscle spasticity associated with neuromuscular diseases such as multiple sclerosis. Cyclobenzaprine, metaxalone, and orphenadrine are used for relief of discomfort associated with painful, acute musculoskeletal conditions.

12. A patient comes to the clinic to receive a Botox injection in her forehead. The patient has adult acne across her forehead. What is the nurse's priority action? A) Hold the injection and consult the health care provider. B) Cleanse the area well with an antibacterial soap. C) Apply a topical antibiotic after administering the Botox. D) Provide patient information about post-Botox injection care.

Ans: A Feedback: Botulinum toxins should not be injected into any area with an active infection because of the risk of exacerbation of the infection. As a result, the nurse would hold the injection and consult with the physician, with the expectation the medication would be held until the acne resolved. Cleansing the area well, applying a topical antibiotic, and providing information about postinjection care would not resolve the problem and are not indicated.

1. The nurse is teaching a class on muscular coordination and explains it is the movement of what electrolyte that contributes to the process of muscle contraction and relaxation? A) Calcium B) Chloride C) Magnesium D) Hydrogen

Ans: A Feedback: Calcium is released from the sarcoplasmic reticulum, which leads to the binding of calcium with troponintropomyosin. This leads to contraction of the muscle fiber. The calcium pump then moves calcium back into the sarcoplasmic reticulum, which leads to relaxation of muscle fiber. Chloride, magnesium, and hydrogen are not involved in this process.

20. A 3-year-old girl with a diagnosis of spasticity caused by cerebral palsy has been admitted to the unit. The physician has ordered dantrolene to see if it relieves the spasticity in the child's arms and hands. The nurse would schedule this child for what routine screenings? A) Central nervous system and gastrointestinal (GI) function B) Respiratory and cardiovascular (CV) function C) Growth and development D) Renal and hepatic function

Ans: A Feedback: Children prescribed dantrolene should be routinely and regularly screened for central nervous system and gastrointestinal (including hepatic) toxicity. Growth and development should be routinely screened in all children. Renal, respiratory, and CV screening is not indicated.

27. A patient has been diagnosed with multiple sclerosis and experiences spasticity in several muscle groups. What drug would the nurse anticipate will be ordered as the drug of choice to manage spasticity associated with neuromuscular diseases? A) Dantrolene (Dantrium) B) Baclofen (Lioresal) C) Carisoprodol (Soma) D) Botulinum toxin type B (Myobloc)

Ans: A Feedback: Dantrolene directly affects peripheral muscle contraction, and has become important in the management of spasticity associated with neuromuscular diseases. Baclofen, carisoprodol, and botulinum toxin type B are not the drugs of choice for management of spasticity in neuromuscular disease.

15. A patient with severe spasticity sees his physician. The physician orders dantrolene. In what circumstances is the drug dantrolene contraindicated? A) Spasticity that contributes to upright position B) Spasticity that involves both legs C) Spasticity that involves the arm and the leg on the same side D) Spasticity that contributes to mobility

Ans: A Feedback: Dantrolene is contraindicated in the presence of any known allergy to the drug. It is also contraindicated in the following conditions: spasticity that contributes to locomotion, upright position, or increased function, which would be lost if that spasticity was blocked; active hepatic disease, which might interfere with metabolism of the drug and because of known liver toxicity; and lactation because the drug may cross into breast milk and cause adverse effects in the infant. The other options would not contraindicate the medication.

5. The nurse admits a child diagnosed with tetanus. What medication will the nurse expect to administer? A) Methocarbamol (Robaxin) B) Baclofen (Lioresal) C) Dantrolene (Dantrium) D) Diphenhydramine (Benadryl)

Ans: A Feedback: Methocarbamol is the drug of choice if a child needs to be treated for tetanus. Baclofen and dantrolene are not recommended for use with children. Diphenhydramine is not indicated for treatment of tetanus.

33. After administering a centrally acting skeletal muscle relaxant, what other independent nursing measures might the nurse implement to relieve pain and reduce spasm? A) Rest of the affected muscle B) Application of cold C) Physical therapy D) Order of a nonsteroidal anti-inflammatory drug

Ans: A Feedback: Other measures in addition to drugs should be used to alleviate muscle spasm and pain. The nurse can independently encourage rest of the affected muscle and provide heat applications to increase blood flow to the area to remove the pain-causing chemicals.

17. When spinal reflexes involve synapses with interneurons within the spinal cord, what physiological adjustments are made? A) Coordinate movement and position B) Adjust response and recovery C) Adjust to upright position D) Coordinate balance

Ans: A Feedback: Other spinal reflexes may involve synapses with interneurons within the spinal cord, which adjust movement and response based on information from higher brain centers to coordinate movement and position. Spinal reflexes do not adjust response and recovery, adjust the body to the upright position, or coordinate balance.

3. A nurse is providing discharge teaching for a patient who will be going home on cyclobenzaprine (Flexeril) prescribed for his acute musculoskeletal pain. The nurse will stress that the patient should avoid what? A) Drinking alcohol B) Taking antiemetics C) Taking antihistamines D) Taking antibiotics

Ans: A Feedback: Taking cyclobenzaprine with alcohol can cause an increase in central nervous system depression. The nurse should stress that this combination should be avoided due to possible injury or severe body system depression that could lead to coma or death. No significant concerns exist with the use of antiemetics, antihistamines, or antibiotics with this drug.

30. What part of the brain does the nurse recognize the patient is using when making precise, intentional movements? A) Pyramidal tract B) Substantia nigra C) Broca's area D) Extrapyramidal tract

Ans: A Feedback: Upper-level controls of muscle activity include the pyramidal tract in the cerebellum, which regulates precise intentional muscle movement, and the extrapyramidal tract in the cerebellum and basal ganglia, which coordinates crude movements related to unconscious muscle activity. Broca's area has to do with speech, not movement. The substantia nigra does not control muscle movement.

14. The nurse is giving discharge instructions to a patient who just had Botox A injections around her eyes. What adverse effects would the nurse include in her discharge instructions? (Select all that apply.) A) Respiratory infections B) Flu-like syndrome C) Droopy eyelids D) Cough E) Diarrhea

Ans: A, B, C Feedback: Adverse effects associated with use of botulinum toxin type A for cosmetic purposes include headache, respiratory infections, flu-like syndrome, and droopy eyelids in severe cases. Adverse effects do not include cough or diarrhea.

13. The patient presents to the emergency department with muscle spasms in the back. What types of injury would the nurse recognize can result in muscle spasm? (Select all that apply.) A) Overstretching a muscle B) Wrenching a joint C) Tearing a tendon or ligament D) Breaking a bone E) Exercising too vigorously.

Ans: A, B, C Feedback: Muscle spasms often result from injury to the musculoskeletal system (e.g., overstretching a muscle, wrenching a joint, tearing a tendon or ligament). These injuries can cause violent and painful involuntary muscle contractions. Breaking a bone or exercising would not cause muscle spasms unless one of the other options was involved.

24. The nurse is caring for a patient who is having a pump placed to deliver intrathecal baclofen and another patient who will receive dantrolene as a muscle relaxant. What nursing diagnosis would be appropriate for both care plans? (Select all that apply.) A) Acute pain related to GI effects of drug B) Risk for injury related to central nervous system (CNS) effects C) Disturbed body image related to muscle pain D) Disturbed thought processes related to CNS effects E) Deficient knowledge related to procedure

Ans: A, B, D Feedback: Acute pain related to GI effects of drug, risk for injury related to CNS effects, and disturbed thought processes related to CNS effects all apply to both patients. Disturbed body image may apply to the patient having the pump placed, but this is not related to muscle pain. Only the patient having the pump placed would need information related to the procedure.

9. A young woman attends a Botox Party and is injected with botulinum toxin type A to decrease frown lines between her eyebrows. Later that evening the patient is admitted to the emergency department and is hysterical, because she cannot move her eyebrows. The nurse explains that that toxin causes what? A) The toxin causes muscle death, which smoothes wrinkles in the area. B) The toxin causes muscle paralysis, preventing movement and relieving wrinkles. C) The drug is a toxin to nerves in the area. D) The drug is a permanent muscle relaxant and the muscles will never move again.

Ans: B Feedback: Botulinum toxin types A and B bind directly to the receptor sites of motor nerve terminals and inhibit the release of acetylcholine, leading to local muscle paralysis. These two drugs are injected locally and used to paralyze or prevent the contractions of specific muscle groups. The action smoothes wrinkles in the area, but does not cause muscle death. The effect is temporary and does not cause nerve death. The other options are false statements.

32. What is the drug of choice for an older adult or a patient with hepatic or renal impairment? A) Baclofen B) Carisoprodol C) Chlorzoxazone D) Cyclobenzaprine

Ans: B Feedback: Carisoprodol is the centrally acting skeletal muscle relaxant of choice for older patients and for those with hepatic or renal impairment. Although the other options may be prescribed, older adults are more likely to experience the adverse effects associated with the drug.

28. The nurse is caring for a patient taking dantrolene. How would the nurse assess the therapeutic effects of this drug? A) Observe the patient when emotionally stressed to assess for exacerbation of spasticity. B) Discontinue the drug for 2 to 4 days and assess for exacerbation of spasticity. C) Measure the amount of spasticity before and after administration of medication. D) Collect a thorough history to ask the patient any improvement has been noticed.

Ans: B Feedback: Periodically discontinue drug for 2 to 4 days to monitor therapeutic effectiveness. A clinical impression of exacerbation of spasticity indicates a positive therapeutic effect and justifies continued use of the drug. It would not be ethical to stress the patient, there is no known measurement of spasticity, and the patient may not be able to relate how much improvement was felt because it is unlikely all spasticity will be eliminated.

4. The nurse provides patient teaching about chlorzoxazone (Paraflex) in preparation for the patient's discharge to home. The nurse evaluates the patient understands potential adverse effects when the patient makes what statement? A) This drug can cause diarrhea. B) My urine may turn orange to purple red while taking this drug. C) My skin may turn yellow but that will go away when I stop taking the drug. D) After I take a pill it will take 2 to 3 hours before I feel the effects.

Ans: B Feedback: The patient indicates an understanding of adverse effects of this drug by stating that his urine may be discolored while using the drug. Chlorzoxazone may discolor the urine, which will turn orange to purple-red when metabolized and excreted. Patients should be warned about this effect to prevent any fears of blood in the urine. Chlorzoxazone usually causes constipation, not diarrhea. The onset of action is usually within an hour after the drug has been taken. Yellow discoloration of the skin would indicate liver damage or dysfunction, which should be reported immediately.

18. What are the simplest nerve pathways in the body? A) Arc reflexes B) Spinal reflexes C) Afferent nerve reflexes D) Spindle gamma loop

Ans: B Feedback: The spinal reflexes are the simplest nerve pathways that monitor movement and posture. Arc reflexes and afferent nerve reflexes are distracters for this question. Spindle gamma loops respond to stretch receptors.

22. Baclofen is a prototype drug for the centrally acting skeletal muscle relaxants. What adverse effects do drugs in this class have? (Select all that apply.) A) Coronary artery disease B) Hypotension C) Urinary frequency D) Dizziness E) Bone marrow suppression

Ans: B, C, D Feedback: Adverse effects include transient drowsiness, dizziness, weakness, fatigue, constipation, headache, insomnia, hypotension, nausea, and urinary frequency. Bone marrow suppression and coronary artery disease are not associated with therapy involving these drugs.

23. When caring for a patient taking dantrolene, what adverse effects would the nurse monitor for? (Select all that apply.) A) Bradycardia B) Hepatitis C) Urinary retention D) Fatigue E) Rash

Ans: B, D, E Feedback: Adverse effects of dantrolene include drowsiness, dizziness, weakness, fatigue, diarrhea, hepatitis, myalgia, tachycardia, transient blood pressure changes, rash, and urinary frequency. Adverse effects of dantrolene do not include bradycardia or urinary retention.

19. The anatomy and physiology instructor is discussing reflex systems with the prenursing class. What system would the instructor say causes a muscle fiber contraction that relieves the stretch? A) Arch reflex system B) Spinal reflex system C) Spindle gamma loop system D) Stretch receptor system

Ans: C Feedback: A spindle gamma loop system responds to stretch receptors or spindles on muscle fibers to cause a muscle fiber contraction that relieves the stretch. In this system, nerves from stretch receptors form a synapse with gamma nerves in the spinal cord, which send an impulse to the stretched muscle fibers to stimulate their contraction. These reflexes are responsible for maintaining muscle tone and keeping an upright position against the pull of gravity and are important in helping venous return when the contracting muscle fibers massage veins to help move the blood toward the heart. The arch reflex system and the stretch receptor system are distracters for this question. The spinal reflex system is not the reflex systems that respond to stretch receptors in the body.

7. The nurse is caring for four patients. Which patient would have the highest risk for hepatotoxicity from dantrolene (Dantrium)? A) An 87-year-old man who is taking a cardiac glycosideh B) A 32-year-old man who is taking an antipsychotic drug C) A 65-year-old woman who is on hormone replacement therapy D) A 48-year-old woman who is taking an antihypertensive agent

Ans: C Feedback: If dantrolene is combined with estrogen, the incidence of hepatocellular toxicity is increased. This combination should be avoided. Nothing indicates that patients taking a cardiac glycoside, an antipsychotic drug, and an antihypertensive would have serious adverse effects when combined with dantrolene therapy.

25. The nurse is caring for a patient who is being discharged home from the rehabilitation unit. Baclofen will be discontinued and the patient will begin taking carisoprodol as an outpatient. What is the nurse's primary consideration about discontinuing administration of baclofen? A) Taper drug over 72 hours to reduce dependence on the drug. B) Alternate doses of baclofen and soma over 10 days to prevent drug withdrawal. C) Taper drug slowly over 1 to 2 weeks to prevent psychoses and hallucinations. D) Start carisoprodol immediately while continuing baclofen at full dose to establish carisoprodol level.

Ans: C Feedback: If using baclofen, taper drug slowly over 1 to 2 weeks to prevent the development of psychoses and hallucinations. Giving both drugs at once would risk toxicity and serious adverse effects and would never be done.

31. The patient reports pain caused by muscle spasms in his back. The nurse assesses the patient as being very anxious and notes how the anxiety results in tensing of muscles. What medication would be most effective in treating this patient? A) Baclofen (Lioresal) B) Botulinum toxin type B (Myobloc) C) Dantrolene (Dantrium) D) Diazepam (Valium)

Ans: D Feedback: Adults complaining of muscle spasm pain that may be related to anxiety often respond very effectively to diazepam, which is a muscle relaxant and anxiolytic. Although many drugs, including baclofen, will treat the muscle spasm, diazepam also reduces anxiety. Dantrolene would be better indicated for spasticity than for spasm and botulinum toxin type B is not prescribed for either anxiety or muscle spasm.

16. Which muscle relaxant was found to be embryotoxic in animal studies? A) Carisoprodol (Soma) B) Botulinum toxin A (Botox) C) Cyclobenzaprine (Flexeril) D) Dantrolene (Dantrium)

Ans: D Feedback: Dantrolene crosses the placenta and was found to be embryotoxic in animal studies. Botulinum toxin A, carisoprodol, and cyclobenzaprine are not known to be embryotoxic.

29. What drug would the nurse expect to administer to the patient experiencing malignant hyperthermia? A) Orphenadrine B) Metaxalone C) Chlorzoxazone D) Dantrolene

Ans: D Feedback: Indications for dantrolene include control of clinical spasticity resulting from upper motor neuron disorders; preoperatively to prevent or attenuate the development of malignant hyperthermia in susceptible patients; IV for management of fulminant malignant hyperthermia. The other drugs are not indicated for treatment of malignant hyperthermia.

2. A mother brings her 9-year-old son to the clinic for a routine check up. The 9-year-old boy has cerebral palsy and is very spastic. The mother asks the nurse what causes the spasticity in her son. What is the nurse's best response? A) Your son's spasticity is caused by injury to the muscle tissue. B) Your son's spasticity is caused by deficiency of a neurotransmitter called serotonin. C) Your son's spasticity is caused by damaged sensory neurons. D) Your son's spasticity is caused by damaged motor neurons.

Ans: D Feedback: Muscle spasticity is the result of damage to neurons within the central nervous system (CNS) rather than injury to peripheral structures such as the musculoskeletal system. Serotonin is not involved in the process of muscle contraction and relaxation. Although acetylcholine is released and increases muscle cell membrane permeability to sodium, which eventually leads to the release of calcium, this process does play a vital part in muscle contraction and relaxation.

34. The nurse is caring for a patient with an infusing IV who is allowed noting by mouth due to a paralytic ileus. What centrally acting medication could the nurse administer to this patient? A) Chlorzoxazone (Paraflex) B) Carisoprodol (Soma) C) Cyclobenzaprine (Flexeril) D) Orphenadrine (Banflex)

Ans: D Feedback: Only orphenadrine (Banflex) of these options can be given parenterally, either IV or intramuscularly. The other options are available for oral use only.

35. What is the maximum daily dose of cyclobenzaprine (Flexeril) the nurse can administer? A) 20 mg B) 30 mg C) 40 mg D) 60 mg

Ans: D Feedback: The normal daily dosage of cyclobenzaprine is 10 mg taken orally t.i.d., and it can be increased to a maximum of 60 mg per day.

10. A patient has stepped on a rusty nail and is exhibiting signs of muscle rigidity and contractions. The patient's wife called the emergency department (ED) and the triage nurse told her to bring him in. The ED nurse will have which drug available for administration when the patient arrives? A) Carisoprodol (Soma) B) Cyclobenzaprine (Flexeril) C) Metaxalone (Skelaxin) D) Methocarbamol (Robaxin)

Ans: D Feedback: The patient is exhibiting signs of tetanus and methocarbamol (Robaxin) is indicated for treatment. Carisoprodol, cyclobenzaprine, and metaxalone are not used to treat tetanus.

26. The nurse is caring for a patient receiving intrathecal baclofen via pump while participating in rigorous rehabilitation therapy. What is the nurse's priority to monitor related to adverse effects of this drug? A) Blood pressure B) Pulse pressure C) Spasticity D) Respiratory status

Ans: D Feedback: The priority to monitor is respiratory status. One of the primary adverse effects of this drug is central nervous system (CNS) depression. If the patient receives too much medication, or reaches toxic levels, respiratory rate will decline as the result of excessive CNS depression and the drug dosage will either be adjusted downward or the drug may be held until the patient's respirations improve. Monitoring other vital signs including blood pressure and pulse is indicated but is not the priority.

8. The nurse alerts the patient to what adverse effect of tizanidine (Zanaflex) that could cause injury? A) Constipation B) Dry mouth C) Fatigue D) Hypotension

Ans: D Feedback: Tizanidine has been associated with hypotension, which could be a safety risk especially if the patient is also taking an antihypertensive drug. Constipation, dry mouth, and fatigue are common adverse effects that do not pose a safety risk.