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 A
Explanation
Rationale:
A. Potassium 3.1 mEq/L (3.5 to 5 mEq/L): Hypokalemia increases the risk of digoxin toxicity because low potassium levels enhance digoxin’s effects on the myocardium, potentially leading to arrhythmias and other toxic effects. Monitoring electrolytes is crucial for clients taking digoxin, especially when on diuretics like furosemide.
B. WBC count 12,000/mm³ (5,000 to 10,000/mm³): An elevated WBC may indicate infection or inflammation but does not directly influence digoxin toxicity. This finding requires assessment but is not a risk factor for digoxin-related complications.
C. Fasting glucose 150 mg/dL (74 to 106 mg/dL): Elevated glucose reflects hyperglycemia but does not affect digoxin levels or toxicity risk. It should be managed separately according to the client’s metabolic needs.
D. Triglycerides 140 mg/dL (35 to 135 mg/dL): Mildly elevated triglycerides are a cardiovascular risk factor but do not directly increase the likelihood of digoxin toxicity. Lipid management is a separate consideration.
Correct Answer is C
Explanation
Rationale:
A. Monitor the IV site every 8 hours: In infants, IV sites should be assessed much more frequently, typically every 1–2 hours, due to their fragile veins and higher risk of infiltration or phlebitis. Monitoring every 8 hours is insufficient for safety.
B. Use gauze to cover the IV insertion site: Transparent dressings are preferred for infants because they allow continuous visualization of the IV site for signs of infiltration, phlebitis, or infection. Gauze obscures the site and may delay detection of complications.
C. Obtain a 24-gauge catheter: A 24-gauge catheter is appropriate for peripheral IV access in infants. It is small enough to fit delicate veins while allowing adequate fluid and medication administration safely.
D. Insert the catheter into the foot: Foot veins are generally avoided in infants due to higher risk of complications and limited accessibility. Preferred sites include veins on the hands, forearms, or scalp, which are safer and easier to monitor.
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