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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Airway obstruction is the priority because burns to the head, neck, and chest can compromise the airway due to swelling, soot, and edema. Immediate assessment and intervention are critical to ensure the airway remains patent and to prevent respiratory distress.
B. While infection is a significant risk in burn patients, addressing airway concerns takes precedence to prevent immediate life-threatening complications.
C. Paralytic ileus is a concern in burn patients but is less immediate compared to the risk of airway obstruction.
D. Fluid imbalance is crucial in burn management, but ensuring a clear airway is the immediate priority to prevent severe complications such as asphyxia.
Correct Answer is D
Explanation
A. Decreased specific gravity is not typical of right-sided heart failure. Increased specific gravity is often associated with fluid retention.
B. PAWP is more relevant for left-sided heart failure; right-sided heart failure would typically not show an increase in PAWP.
C. BNP levels usually increase in heart failure, including right-sided heart failure, not decrease.
D. Elevated CVP and jugular vein distention are classic signs of right-sided heart failure due to increased venous pressure and fluid overload.
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