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: Increased glucose levels are not a positive outcome of the client's interventions, but rather a sign of impaired glucose metabolism and insulin resistance, which can increase the risk of cardiovascular disease. The Mediterranean diet can help lower glucose levels by providing complex carbohydrates, fiber, and healthy fats, which can improve insulin sensitivity and blood sugar control.
Choice B reason: Increased HDL levels are a positive outcome of the client's interventions, as HDL stands for high-density lipoprotein, which is the "good" cholesterol that helps remove excess cholesterol from the arteries and protect against atherosclerosis and cardiovascular disease. The Mediterranean diet can help increase HDL levels by providing monounsaturated and polyunsaturated fats, such as olive oil, nuts, seeds, and fish, which can boost HDL production and function.
Choice C reason: Increased LDL levels are not a positive outcome of the client's interventions, but rather a sign of increased cholesterol deposition and inflammation in the arteries, which can lead to plaque formation and cardiovascular disease. LDL stands for low-density lipoprotein, which is the "bad" cholesterol that carries cholesterol from the liver to the cells. The Mediterranean diet can help lower LDL levels by providing antioxidants, fiber, and plant sterols, which can reduce LDL synthesis and oxidation.
Choice D reason: Increased triglyceride levels are not a positive outcome of the client's interventions, but rather a sign of increased fat storage and metabolic syndrome, which can increase the risk of cardiovascular disease. Triglycerides are a type of fat that circulates in the blood and provides energy to the cells. The Mediterranean diet can help lower triglyceride levels by providing omega-3 fatty acids, which can modulate triglyceride synthesis and breakdown.
Correct Answer is B
Explanation
Choice D reason:A metallic taste in the mouth is not a recognized symptom of hyperglycemia. It may occur in other conditions, such as certain medication side effects, infections, or metabolic disorders, but it is not specific to diabetes or high blood glucose levels. Including this as a sign of hyperglycemia could lead to confusion or misinterpretation of symptoms.
Choice A reason: Anxiety is not a specific symptom of hyperglycemia, although it can be associated with stress or other psychological factors that can affect blood sugar levels. Anxiety can also be a symptom of hypoglycemia, or low blood sugar, which requires immediate treatment.
Choice B reason: Hyperventilation, characterized by deep and rapid breathing, is a critical manifestation of severe hyperglycemia, particularly in cases ofdiabetic ketoacidosis (DKA). When blood glucose levels are extremely high, the body may produce ketones, leading to metabolic acidosis. To compensate, the client may developKussmaul respirations, a type of hyperventilation aimed at expelling excess carbon dioxide. This is a medical emergency and requires immediate intervention. Teaching the client to recognize hyperventilation as a sign of severe hyperglycemia is essential for timely treatment and prevention of complications.
Choice C reason: Cool skin is not a symptom of hyperglycemia, but rather a sign of poor circulation, which can be a complication of diabetes. Diabetes can damage the blood vessels and nerves that supply blood and oxygen to the skin, especially in the feet and legs. This can lead to skin problems, infections, and ulcers.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today