A client with myasthenia gravis has lost 6 kg of weight over the last 2 months. What should the nurse suggest to improve this client's nutritional status?
Plan medication doses to occur before meals
Restrict drinking fluids before and during meals
Increase the amount of fat and carbohydrates in meals
Eat three large meals per day
The Correct Answer is A
Choice A reason: Planning medication doses to occur before meals is a good suggestion to improve the client's nutritional status. Myasthenia gravis is a neuromuscular disorder that causes weakness and fatigue of the voluntary muscles, especially those involved in chewing and swallowing. Taking anticholinesterase medications before meals can enhance muscle strength and coordination, and make it easier for the client to eat and avoid choking or aspiration.
Choice B reason: Restricting drinking fluids before and during meals is not a good suggestion to improve the client's nutritional status. Fluid intake is important for hydration and digestion, and should not be limited unless there is a medical reason, such as fluid overload or heart failure. Drinking fluids before and during meals can also help lubricate the food and prevent dryness or irritation of the mouth and throat.
Choice C reason: Increasing the amount of fat and carbohydrates in meals is not a good suggestion to improve the client's nutritional status. Fat and carbohydrates are sources of energy, but they can also increase the risk of obesity, diabetes, or cardiovascular disease if consumed excessively. A balanced diet that includes adequate protein, vitamins, minerals, and fiber is more beneficial for the client's health and well-being.
Choice D reason: Eating three large meals per day is not a good suggestion to improve the client's nutritional status. Eating large meals can be difficult and exhausting for the client with myasthenia gravis, as their muscle strength and endurance may decline over time. Eating smaller and more frequent meals can help maintain the energy level and prevent fatigue or hunger.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Monitoring vital signs and neurological status frequently is a priority intervention for a client who has experienced a hemorrhagic stroke, as it helps to detect any changes in the client's condition and guide appropriate treatment. Hemorrhagic stroke is a medical emergency that occurs when a blood vessel in the brain ruptures and causes bleeding into the brain tissue. This can lead to increased intracranial pressure, cerebral edema, and brain damage. Therefore, the nurse should monitor the client's blood pressure, pulse, respiration, temperature, level of consciousness, pupil reaction, motor function, and sensory function frequently and report any abnormalities to the health care provider.
Choice B reason: Maintaining strict bed rest to minimize cerebral blood flow is not a priority intervention for a client who has experienced a hemorrhagic stroke, as it may not prevent further bleeding or improve the client's outcome. In fact, strict bed rest may increase the risk of complications such as deep vein thrombosis, pulmonary embolism, pneumonia, pressure ulcers, and muscle atrophy. The nurse should follow the health care provider's orders regarding the client's activity level and position. The nurse should also provide adequate hydration, nutrition, skin care, and comfort measures to the client.
Choice C reason: Administering anticoagulant medications as prescribed is not a priority intervention for a client who has experienced a hemorrhagic stroke, as it may worsen the bleeding and increase the risk of intracranial hemorrhage. Anticoagulant medications are used to prevent or treat ischemic stroke, which is caused by a blood clot that blocks a blood vessel in the brain. However, anticoagulant medications are contraindicated in hemorrhagic stroke, as they interfere with the blood's ability to clot and stop the bleeding. The nurse should avoid giving any medications that may affect coagulation or platelet function to the client unless ordered by the health care provider.
Choice D reason: Assisting the client with active range of motion exercises is not a priority intervention for a client who has experienced a hemorrhagic stroke, as it may not improve the client's neurological function or prevent complications. Active range of motion exercises are performed by the client with or without assistance from the nurse to maintain joint mobility and muscle strength. However, these exercises are not indicated in the acute phase of hemorrhagic stroke, as they may increase intracranial pressure or cause pain or discomfort to the client. The nurse should consult with the physical therapist before initiating any exercise program for the client.
Correct Answer is C
Explanation
Choice A reason: Repeat dose in 1 hour for unrelieved headache. This instruction is incorrect because sumatriptan should not be taken more than twice in 24 hours. Taking too much sumatriptan can cause serious side effects, such as high blood pressure, stroke, or heart problems.
Choice B reason: Chew the tablet well before swallowing. This instruction is incorrect because sumatriptan tablets should be swallowed whole with water. Chewing the tablet may affect its absorption and effectiveness.
Choice C reason: If you experience chest pain, call your physician immediately. This instruction is correct because chest pain is a serious and potentially life-threatening side effect of sumatriptan. Chest pain may indicate a heart attack or coronary artery spasm, which require immediate medical attention.
Choice D reason: Take daily to prevent headaches. This instruction is incorrect because sumatriptan is not a preventive medication for migraines. It is only used to treat acute migraine attacks when they occur. Taking sumatriptan daily can cause rebound headaches, which are worse and more frequent than the original ones.
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