A nurse admits an older patient to the emergency room with reports of shortness of breath on exertion and a productive cough.
The nurse reviews the patient's current medications and the patient says, “I take one pink pill every morning.”. The nurse asks the name of the drug and the patient says she doesn’t know.
The patient cannot supply the name of the drug or the purpose of taking it either.
This happens with four other medications the patient says she takes.
What is an appropriate nursing diagnosis for this patient?

Choice A rationale

Myasthenia gravis primarily affects voluntary muscles, especially those involved in breathing and facial movements. Gastrointestinal (GI) and lower extremity muscles are generally not the main muscles affected by this condition. It is an autoimmune disorder that impacts the neuromuscular junction, where nerves communicate with muscles, leading to muscle weakness and fatigue.

Choice B rationale

The central nervous system (CNS), memory, and cognition are not typically impacted by myasthenia gravis. This disorder primarily involves peripheral nervous system issues that affect voluntary muscle control rather than cognitive functions. Myasthenia gravis does not cause alterations in memory or cognition as seen with central nervous system disorders like Alzheimer's disease.

Choice C rationale

Myasthenia gravis notably affects respiratory and facial muscles. The autoimmune attack on acetylcholine receptors leads to muscle weakness, particularly in muscles controlling eye movements, facial expressions, and breathing. Patients may experience difficulty breathing, swallowing, and maintaining an open airway due to this muscle weakness.

Choice D rationale

The cardiovascular system and postural muscles are not commonly affected by myasthenia gravis. This condition involves the neuromuscular junction and leads to fatigue in voluntary muscles, primarily those involved in eye movement, facial expressions, and respiration. Cardiovascular symptoms are not a direct consequence of myasthenia gravis.

Choice A rationale

Ineffective health maintenance is appropriate due to the patient's inability to provide names and purposes of medications, indicating insufficient knowledge of their regimen.

Choice B rationale

Noncompliance implies intentional refusal of medication, which is not evident here as the patient is unaware rather than refusing.

Choice C rationale

Acute confusion is not indicated as the patient appears oriented and not disoriented.

Choice D rationale

Risk-prone health behavior is not appropriate as it suggests engagement in harmful activities, which is not described.