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 B
Explanation
Choice A reason: Performing carotid massage is not an appropriate action for a nurse to take when a client has signs of a stroke, as it may worsen the condition or cause complications. Carotid massage is a technique that involves applying pressure to the carotid artery in the neck to stimulate the vagus nerve and slow down the heart rate. It is used to treat some types of arrhythmias, such as supraventricular tachycardia. However, carotid massage may dislodge a blood clot or plaque from the carotid artery and cause an embolic stroke, which is a type of ischemic stroke that occurs when a blood clot travels to the brain and blocks a blood vessel. Carotid massage may also cause bradycardia, hypotension, or syncope, which can reduce the blood flow to the brain and worsen the ischemic damage.
Choice B reason: Calling for help is an appropriate action for a nurse to take when a client has signs of a stroke, as it initiates the emergency response and allows for prompt evaluation and treatment. Stroke is a medical emergency that occurs when the blood supply to a part of the brain is interrupted, causing brain cells to die. The sooner the stroke is recognized and treated, the better the chances of survival and recovery. Therefore, the nurse should call for help as soon as possible and activate the stroke protocol in the facility.
Choice C reason: Providing the client with water to test the gag reflex is not an appropriate action for a nurse to take when a client has signs of a stroke, as it may cause aspiration or choking. A gag reflex is an involuntary contraction of the throat muscles that prevents foreign objects from entering the airway. It is tested by touching the back of the throat with a tongue depressor or a cotton swab. However, this test is not indicated in a client who has signs of a stroke, as it may trigger vomiting or coughing, which can increase intracranial pressure or cause bleeding. Moreover, giving water to a client who has signs of a stroke may be dangerous, as they may have dysphagia (difficulty swallowing) or facial weakness, which can impair their ability to swallow safely and increase the risk of aspiration pneumonia.
Choice D reason: Administering thrombolytics is not an appropriate action for a nurse to take when a client has signs of a stroke, as it may be contraindicated or harmful depending on the type and timing of the stroke. Thrombolytics are medications that dissolve blood clots and restore blood flow. They are used to treat ischemic stroke, which is caused by a blood clot that blocks a blood vessel in the brain. However, thrombolytics are not effective for hemorrhagic stroke, which is caused by bleeding into or around the brain. In fact, thrombolytics may worsen hemorrhagic stroke by increasing bleeding and intracranial pressure. Therefore, thrombolytics should only be given after confirming the type of stroke by imaging tests such as computed tomography (CT) scan or magnetic resonance imaging (MRI). Thrombolytics should also be given within a specific time window after the onset of symptoms, usually within 3 to 4.5 hours, as they may lose their effectiveness or cause complications if given too late. Therefore, administering thrombolytics is not an action that a nurse can take without proper assessment and orders from the health care provider.
Correct Answer is D
Explanation
Choice A reason: The client's financial resources is not the most important factor for the nurse to consider. Although Meals-on-Wheels is a low-cost or free service that provides nutritious meals to homebound seniors and people with disabilities, it does not require a specific income level or financial status to qualify. The nurse should focus on the client's nutritional and functional needs, rather than their economic situation.
Choice B reason: The client's level of family support is not the most important factor for the nurse to consider. Although having family members who can assist with meal preparation and delivery can be helpful and beneficial for the client, it is not a requirement or a guarantee for receiving Meals-on-Wheels. The nurse should assess the client's individual capabilities and preferences, rather than their family availability or involvement.
Choice C reason: The client's access to transportation is not the most important factor for the nurse to consider. Although having access to transportation can enable the client to obtain food and groceries from other sources, such as stores, markets, or restaurants, it is not a criterion or a barrier for receiving Meals-on-Wheels. The nurse should evaluate the client's dietary and health needs, rather than their mobility or transportation options.
Choice D reason: The client's ability to prepare meals is the most important factor for the nurse to consider. Meals-on-Wheels is designed to serve clients who are unable to cook or shop for themselves due to physical, mental, or social limitations. The nurse should determine if the client has any impairments or challenges that prevent them from preparing their own meals, such as vision loss, arthritis, dementia, or isolation. If the client has difficulty or inability to prepare meals, they may be eligible for Meals-on-Wheels.
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