A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?

Confusion

Increased urinary output

Increased intracranial pressure

Weakness

Answer and Explanation

The Correct Answer is D

A. Confusion is not a typical manifestation of myasthenia gravis but could be related to other issues or conditions.
B. Increased urinary output is not directly associated with myasthenia gravis and is not a primary symptom to monitor.
C. Increased intracranial pressure is not characteristic of myasthenia gravis and is unrelated to the condition.
D. Weakness is a hallmark symptom of myasthenia gravis, resulting from impaired communication between nerves and muscles. It is crucial to monitor and assess for changes in muscle strength and fatigue.

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Correct Answer is B

Explanation

A. Assistive personnel typically do not have the training or authority to perform the critical double-check of blood products.
B. An oncology nurse is a qualified staff member who has the necessary training and experience to correctly verify blood labels and client ID bracelets before transfusion.
C. A phlebotomist is trained in blood collection but is not generally authorized to perform blood transfusion verifications.
D. A senior nursing student may not have the required certification or experience to safely double-check blood transfusion products.

A. "Tuck your chin when you swallow so you won't choke." B. "You should have no trouble swallowing fluids." C. "I will add a thickener to your liquids to prevent aspiration." D. "It is no longer possible for you to choke on or aspirate food."

Correct Answer is C

Explanation

A. Tucking the chin when swallowing can help reduce the risk of aspiration in clients with certain conditions, but after a total laryngectomy, clients are at increased risk for aspiration due to altered anatomy and should have thickened liquids to minimize this risk.

B. Clients who have undergone a total laryngectomy may have difficulties with swallowing and are at risk of aspiration. It is not accurate to say they will have no trouble swallowing fluids without proper assessment and adaptation.

C. Adding a thickener to liquids is a recommended intervention to reduce the risk of aspiration in clients who have had a laryngectomy, as thickened fluids are less likely to be aspirated into the lungs compared to thin liquids.

D. Clients who have had a total laryngectomy are still at risk for choking or aspiration due to changes in their swallowing mechanics and altered anatomy. It is important to take preventive measures, such as thickening liquids.

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A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is selecting a qualified staff member to double-check a blood label with a client ID bracelet prior to infusing a unit of blood. The nurse should identify that which of the following persons is qualified?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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