A nurse is caring for a client who has myasthenia gravis. Which of the following actions should the nurse take?
Instruct the client to take prescribed anticholinesterase with meals
Position the head of the client's bed to 40° while eating
Encourage the client to lie down after eating
Provide the client with food cut into small bites
The Correct Answer is B
Choice A reason: Anticholinesterase medications should be taken 30 minutes before meals, not with meals. This is because they enhance the action of acetylcholine, which improves muscle strength and swallowing ability.
Choice B reason: Positioning the head of the client's bed to 40° while eating helps prevent aspiration and facilitates swallowing. This is the best action for the nurse to take for a client who has myasthenia gravis.
Choice C reason: Encouraging the client to lie down after eating is not advisable, as it increases the risk of aspiration and reflux. The client should remain upright for at least 30 minutes after eating.
Choice D reason: Providing the client with food cut into small bites is not enough to ensure safe and adequate nutrition. The client may still have difficulty swallowing and chewing. The nurse should also offer soft, moist, and easy-to-swallow foods, and avoid foods that are dry, sticky, or hard.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Formula should not be changed to whole milk until the infant is 12 months old, as whole milk does not provide enough iron and other nutrients for the infant's growth and development. Whole milk can also cause intestinal bleeding and increase the risk of allergies in infants younger than 12 months.
Choice B reason: Formula that remains in the bottle should not be used for another feeding, as it can harbor bacteria and cause infection. Any formula that is not consumed within one hour of preparation or feeding should be discarded.
Choice C reason: If the infant turns away after taking most of the feeding, it is a sign that the infant is full and satisfied. The nurse should instruct the parents to stop the feeding and burp the infant. Forcing the infant to finish the bottle can cause overfeeding and vomiting.
Choice D reason: If the infant is gaining weight too rapidly, diluting the formula is not a safe or effective solution. Diluting the formula can cause water intoxication, electrolyte imbalance, and malnutrition in the infant. The nurse should advise the parents to consult with the infant's doctor about the appropriate amount and type of formula for the infant.
Correct Answer is B
Explanation
Choice A reason: Reducing caloric intake by 200 calories a day may not be enough to achieve significant weight loss for a client who is obese. The recommended daily calorie deficit for weight loss is 500 to 750 calories, which can result in a loss of 1 to 1.5 pounds per week¹.
Choice B reason: Losing 5 percent of body weight can improve glycemic control and reduce the need for glucose-lowering medications for a client who has type 2 diabetes. Studies have shown that weight loss of 5 to 10 percent can lower HbA1c levels by 0.5 to 1.0 percentage points².
Choice C reason: Exercising for 30 minutes three times a week may not be sufficient to lose 1 pound per week. The recommended amount of physical activity for weight loss is at least 150 minutes of moderate-intensity aerobic exercise per week, plus resistance training at least twice a week³.
Choice D reason: Drinking 16 ounces of apple juice is not advisable if the blood glucose level drops during exercise, as it can cause hyperglycemia. Apple juice contains about 48 grams of carbohydrates, which is equivalent to four servings of glucose tablets⁴. The recommended treatment for hypoglycemia is to consume 15 to 20 grams of fast-acting carbohydrates, such as glucose tablets, gel, or juice, and recheck the blood glucose level after 15 minutes⁵.
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