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 D

Explanation

A. Frothy pink drainage is more characteristic of recent or active bleeding rather than an upper gastrointestinal bleed.
B. Greenish-yellow drainage typically indicates bile or gastric secretions rather than blood.
C. Dark amber drainage might suggest older, degraded blood but is less specific to an active upper GI bleed.
D. Coffee-ground drainage is indicative of older, partially digested blood and is expected in cases of upper gastrointestinal bleeding due to the breakdown of blood in the stomach.

A. Eyelets are not visible B. Crepitus in the area above and surrounding the insertion site C. Bubbling of the water in the water seal chamber with exhalation D. Movement of the trachea toward the unaffected side

Correct Answer is D

Explanation

A. Eyelets not being visible may be a normal finding, as they can be covered by the dressing. This is not necessarily indicative of a problem with the chest tube.

B. Crepitus, or subcutaneous emphysema, is concerning and should be monitored but is not immediately life-threatening compared to other signs of complications.

C. Bubbling in the water seal chamber with exhalation is expected and indicates that the chest tube is functioning correctly. Continuous bubbling, however, may suggest an air leak.

D. Movement of the trachea toward the unaffected side is indicative of a mediastinal shift, which can occur due to tension pneumothorax or other significant complications. This is an urgent condition that requires immediate provider notification and intervention.

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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 caring for a client who has an active upper gastrointestinal bleed. After inserting an NG tube into the client, which of the following findings should the nurse anticipate?

Correct Answer is D

Explanation

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

Correct Answer is D

Explanation

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