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 B
Explanation
Choice A reason: Setting a weight loss goal is an important step in the weight management process, but it is not the first action the nurse should take. The nurse should first assess the client's readiness and willingness to change, as well as the factors that motivate the client to lose weight.
Choice B reason: Identifying the client's motivation is the first action the nurse should take, as it helps the nurse to tailor the interventions to the client's needs and preferences. The nurse should explore the client's reasons for wanting to lose weight, such as improving health, appearance, or self-esteem, and use them as positive reinforcement.
Choice C reason: Discussing behavior modification is a key component of weight management, but it is not the first action the nurse should take. The nurse should first identify the client's motivation and then help the client to develop realistic and specific goals and strategies to change their eating and physical activity habits.
Choice D reason: Referring the client to a dietitian is a helpful action, but it is not the first action the nurse should take. The nurse should first identify the client's motivation and then collaborate with the dietitian to provide individualized and evidence-based dietary advice and education to the client.
Correct Answer is A
Explanation
Choice A reason: A low-protein diet is essential for clients who have PKU, as they cannot metabolize the amino acid phenylalanine. High levels of phenylalanine can cause intellectual disability and other neurological problems. A low-protein diet should be started before pregnancy and maintained throughout pregnancy to prevent fetal harm.
Choice B reason: Serum bilirubin is not related to PKU. It is a product of red blood cell breakdown and is elevated in conditions such as jaundice, liver disease, or hemolytic anemia. It does not need to be monitored routinely in clients who have PKU.
Choice C reason: Diet sodas are not recommended for clients who have PKU, as they often contain artificial sweeteners such as aspartame, which is a source of phenylalanine. Diet sodas should be avoided completely or consumed very sparingly by clients who have PKU.
Choice D reason: Breastfeeding will not prevent the baby from developing PKU, as PKU is a genetic disorder that is inherited from both parents. If both parents have PKU, the baby will have a 100% chance of having PKU. If one parent has PKU and the other is a carrier, the baby will have a 50% chance of having PKU. If one parent has PKU and the other is not a carrier, the baby will not have PKU but will be a carrier. Breastfeeding may provide some benefits for the baby, such as immunity and bonding, but it will not affect the baby's PKU status.
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