The nurse is caring for a client with a spinal cord injury who is experiencing muscle spasticity. The healthcare provider prescribes baclofen. The nurse should monitor the client for which adverse effect of this medication?

Correct Answer: B

Rationale: Baclofen, a muscle relaxant for SCI spasticity, commonly causes drowsiness (B) due to CNS depression. Hyperglycemia (A), hypertension (C), or tachycardia (D) aren't typical. B is correct. Rationale: Sedation is a frequent side effect, requiring monitoring for safety, per pharmacology, especially in SCI patients with altered mobility.

Correct Answer: C

Rationale: Involving the client in setting goals ensures outcomes reflect their values and needs, enhancing motivation and adherence. For example, a client with diabetes might prioritize dietary control over exercise, tailoring care to their lifestyle. Combining diagnoses or limiting them risks oversimplification, while team-driven goals may ignore client preferences. Client collaboration fosters autonomy and relevance like aiming for stable glucose levels making this the most effective approach for meaningful, achievable outcomes in nursing care planning.

Correct Answer: D

Rationale: Only nurses directly involved in a client's care can access their chart, per privacy laws like HIPAA, ensuring confidentiality. Being unrelated, licensed, or having verbal permission doesn't grant rights without a care role. This protects client information, a legal and ethical duty in nursing.

Correct Answer: D

Rationale: Counting the apical pulse for one full minute is most accepted, ensuring accuracy, especially if irregular. Shorter counts or dual pulse checks risk error. Nurses rely on this for precise cardiac assessment.

Correct Answer: D

Rationale: Pain threshold is the stimulation level causing pain, distinct from relief, tolerance, or averages. Nurses clarify this for client understanding.