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.
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Related Questions
Correct Answer is C
Explanation
A. Positioning the client in a high-Fowler's position might not be appropriate immediately after a spinal fusion due to potential strain on the surgical site; the position should be adjusted based on specific postoperative orders.
B. The knee-chest position is not typically used postoperatively for a laminectomy with spinal fusion and could cause discomfort or complications.
C. Monitoring sensory perception of the lower extremities is crucial after spinal surgery to assess for potential complications such as nerve damage or compromised circulation.
D. Strict bed rest is not generally required for the entire first 48 hours; mobility and positioning should be based on the surgeon's recommendations and the client's tolerance.
Correct Answer is B
Explanation
A. Xerostomia, or dry mouth, can occur due to various causes, including medications, but it is not an infectious condition linked directly to AIDS.
B. Candidiasis, or oral thrush, is a common opportunistic infection in clients with AIDS due to their weakened immune system and low CD4-T-cell count. It is caused by the overgrowth of Candida species in the mouth.
C. Gingivitis, an inflammation of the gums, can occur in immunocompromised individuals but is not as specific or common in AIDS as candidiasis.
D. Halitosis, or bad breath, can be a symptom of various conditions, including oral infections, but it is not a specific infectious condition associated with AIDS like candidiasis is.
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