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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Increased cholesterol is not an indication that the weight loss program has been effective, as it is a risk factor for cardiovascular disease and stroke. The nurse should expect the client's cholesterol level to decrease as a result of the weight loss program, as it can lower the production and absorption of cholesterol in the body.
Choice B reason: Increased glycosylated hemoglobin (HbA1c) is not an indication that the weight loss program has been effective, as it is a measure of the average blood glucose level over the past 2 to 3 months. The nurse should expect the client's HbA1c level to decrease as a result of the weight loss program, as it can improve the insulin sensitivity and glucose metabolism of the body.
Choice C reason: Increased LDL (low-density lipoprotein) is not an indication that the weight loss program has been effective, as it is the "bad" cholesterol that can accumulate in the arteries and cause atherosclerosis. The nurse should expect the client's LDL level to decrease as a result of the weight loss program, as it can reduce the synthesis and secretion of LDL in the liver.
Choice D reason: Increased HDL (high-density lipoprotein) is an indication that the weight loss program has been effective, as it is the "good" cholesterol that can remove excess cholesterol from the blood and transport it to the liver for excretion. The nurse should expect the client's HDL level to increase as a result of the weight loss program, as it can enhance the activity and expression of HDL in the body.
Correct Answer is B
Explanation
Choice A reason: Changing the feeding to a continuous infusion may not improve the constipation, as it does not address the fluid deficit or the fiber content of the formula. Continuous infusion may also increase the risk of aspiration, diarrhea, and bacterial contamination.
Choice B reason: Increasing the amount of free water can help prevent or treat constipation by hydrating the stool and facilitating its passage. The client's fluid intake and output indicate a fluid deficit, which can contribute to constipation. The recommended fluid intake for adults is 30 to 35 mL/kg/day.
Choice C reason: Decreasing the infusion rate of feeding may worsen the constipation, as it reduces the caloric and fluid intake of the client. The infusion rate should be based on the client's nutritional needs and tolerance.
Choice D reason: Requesting a prescription for a diuretic is not appropriate, as it would further dehydrate the client and aggravate the constipation. Diuretics are indicated for clients with fluid overload, not fluid deficit.
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