The nurse is caring for an 80-year-old patient who has just begun taking a Thiazide diuretic to treat hypertension.
What is an important aspect of care for this patient?

Choice A rationale

Myasthenia gravis primarily affects voluntary muscles, especially those involved in breathing and facial movements. Gastrointestinal (GI) and lower extremity muscles are generally not the main muscles affected by this condition. It is an autoimmune disorder that impacts the neuromuscular junction, where nerves communicate with muscles, leading to muscle weakness and fatigue.

Choice B rationale

The central nervous system (CNS), memory, and cognition are not typically impacted by myasthenia gravis. This disorder primarily involves peripheral nervous system issues that affect voluntary muscle control rather than cognitive functions. Myasthenia gravis does not cause alterations in memory or cognition as seen with central nervous system disorders like Alzheimer's disease.

Choice C rationale

Myasthenia gravis notably affects respiratory and facial muscles. The autoimmune attack on acetylcholine receptors leads to muscle weakness, particularly in muscles controlling eye movements, facial expressions, and breathing. Patients may experience difficulty breathing, swallowing, and maintaining an open airway due to this muscle weakness.

Choice D rationale

The cardiovascular system and postural muscles are not commonly affected by myasthenia gravis. This condition involves the neuromuscular junction and leads to fatigue in voluntary muscles, primarily those involved in eye movement, facial expressions, and respiration. Cardiovascular symptoms are not a direct consequence of myasthenia gravis.

Choice A rationale

Using an “ouch” scale, such as the Wong-Baker FACES Pain Rating Scale, is appropriate for young children. It allows them to express their pain intensity in a way that is understandable and relatable to their age group.

Choice B rationale

Encouraging a six-year-old to request pain medication may not be effective, as they might not understand when they need it or might be reluctant to ask.

Choice C rationale

Waiting to administer pain medication until the child begins to cry can delay pain relief, leading to unnecessary discomfort and anxiety.

Choice D rationale

Asking a young child to rate their pain on a scale of 1 to 10 might be confusing and less effective than using a more child-friendly method like the “ouch” scale.