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. Documenting the time of the seizure is important but is not the immediate priority. The priority is to ensure the client's safety during the seizure.

B. Turning the client's head to the side is the first action to take during a seizure. This helps prevent aspiration and keeps the airway clear by allowing any secretions to drain from the mouth.

C. Loosening clothing around the client's waist is important for comfort but should be done after ensuring the client's immediate safety. The primary focus should be on airway protection and preventing injury.

D. Checking the client's motor strength is not immediately relevant during an active seizure. The priority is to manage the seizure and ensure the client's safety, with detailed assessments to follow once the seizure has ended.

A. Limit the number of health care workers entering the room. B. Take the client's temperature once per shift. C. Provide the client with fresh fruit to avoid constipation. D. Insert an indwelling catheter to monitor sediment in the urine.

Correct Answer is A

Explanation

A. Limiting the number of health care workers entering the room helps reduce the risk of infection for immunosuppressed clients, who have weakened immune systems and are more susceptible to infections.
B. For clients with immunosuppression, monitoring the temperature more frequently (e.g., every 4 hours) is important to promptly identify signs of infection.
C. Providing fresh fruit might introduce potential sources of infection; it is safer to provide well-cooked or processed fruits.
D. Inserting an indwelling catheter may increase the risk of infection, and it is generally better to use less invasive methods unless absolutely necessary.

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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

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