A nurse is providing discharge teaching to a client who has generalized myasthenia gravis. Which of the following information should the nurse include?
Encourage the client to eat a large meal in the evening.
Recommend the client eat within 45 min of taking cholinesterase-inhibitor medication.
Recommend the client extend their neck to facilitate swallowing.
Encourage the client to contact an occupational therapist to learn techniques of avoiding aspiration.
The Correct Answer is B
Rationale:
A. Encourage the client to eat a large meal in the evening: Clients with myasthenia gravis experience progressive muscle weakness, especially later in the day. Eating large evening meals increases the risk of fatigue and aspiration because muscle strength is reduced after activity.
B. Recommend the client eat within 45 min of taking cholinesterase-inhibitor medication: Cholinesterase inhibitors, such as pyridostigmine, enhance neuromuscular transmission and improve muscle strength. Eating within 45 minutes of taking the medication ensures optimal swallowing ability and reduces the risk of aspiration by aligning mealtime with peak effect.
C. Recommend the client extend their neck to facilitate swallowing: Extending the neck actually increases the risk of aspiration by opening the airway. Clients should be instructed to flex the neck slightly forward while swallowing to close the airway and promote safe swallowing mechanics.
D. Encourage the client to contact an occupational therapist to learn techniques of avoiding aspiration: While an occupational therapist can provide helpful adaptive techniques, primary aspiration prevention teaching should come directly from the nurse and speech-language pathologist.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Instruct the parent to give the infant water every 3 hr between feedings: Giving water to infants under 6 months can displace nutrient intake and increase the risk of hyponatremia. Breast milk or formula should remain the exclusive source of nutrition at this age.
B. Recommend the parent mix the milk with rice cereal for feedings: Introducing rice cereal at 3 months is not developmentally appropriate and can increase the risk of choking. Cow’s milk lacks the proper nutrient balance, and adding cereal does not correct these deficiencies.
C. Instruct the parent to give 5 mcg of vitamin D daily: While vitamin D supplementation is important for infants, the concern in this scenario is the use of cow’s milk, not vitamin D deficiency. Breastfed infants should receive supplementation, but formula-fed infants typically get adequate vitamin D through fortified formula.
D. Advise the parent to avoid giving cow's milk to the infant prior to 1 year of age: Cow’s milk should not be introduced before 12 months because it lacks iron, vitamin E, and essential fatty acids, and can cause gastrointestinal irritation and occult blood loss.
Correct Answer is D
Explanation
Rationale:
A. Prolonged QT interval: Morphine does not typically cause a prolonged QT interval. QT prolongation is more commonly associated with certain antiarrhythmic or psychotropic medications, not opioid toxicity.
B. Fluid retention: Morphine is not known to cause fluid retention. Signs of toxicity are primarily related to central nervous system and respiratory depression rather than cardiovascular fluid balance.
C. Hyperactive deep tendon reflexes: Morphine toxicity usually depresses neurological function, leading to decreased reflexes rather than hyperactivity. Hyperactive reflexes are not characteristic of opioid overdose.
D. Bradypnea: Respiratory depression, manifested as bradypnea, is a hallmark sign of morphine toxicity. Excessive morphine depresses the brainstem respiratory centers, reducing the rate and depth of respirations, which can be life-threatening if not addressed promptly.
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