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A client with myasthenia gravis has the priority client problem of inadequate nutrition. What assessment is most important?
- A. Ability to chew and swallow without aspiration
- B. Eating 75% of meals and between-meal snacks
- C. Intake greater than output for 3 days
- D. Weight gain of 3 pounds in 1 month
Correct Answer: D
Rationale: Weight gain is the best indicator that the client is receiving enough nutrition. Being able to chew and swallow is important for eating, but adequate nutrition can be accomplished through enteral means if needed. Swallowing without difficulty is necessary for an intact airway. Since the question does not include what the client's meals and snacks consist of, eating 75% may or may not be adequate. Intake and output refers to fluid balance.
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A client with Guillian-Barr syndrome is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority client problem?
- A. Anxiety
- B. Low fluid volume
- C. Inadequate airway
- D. Potential for skin breakdown
Correct Answer: C
Rationale: Airway takes priority. Anxiety is probably present, but a physical diagnosis takes priority over a psychosocial one. The client has no reason to have low fluid volume unless he or she has been unable to drink for some time. If present, airway problems take priority over a circulation problem. An actual problem takes precedence over a risk for a problem.
A client has undergone a percutaneous stereotactic rhizotomy. What instruction by the nurse is most important on discharge from the ambulatory surgical center?
- A. Avoid having teeth pulled for 1 year
- B. Avoid heavy lifting for 6 months
- C. Do not use harsh chemicals on your face
- D. Inform your dentist of this procedure
Correct Answer: C
Rationale: The affected side is left without sensation after this procedure. The client should avoid putting harsh chemicals on the affected side to prevent injury. The other instructions are not necessary.
A client with myasthenia gravis is prescribed pyridostigmine (Mestinon). What teaching should the nurse plan regarding this medication? (Select all that apply.)
- A. Do not eat a full meal for 45 minutes after taking the drug
- B. Seek immediate care if you develop trouble swallowing
- C. Take this drug on an empty stomach for best absorption
- D. The dose may change frequently depending on symptoms
- E. Your urine may turn a reddish-orange color while on this drug
Correct Answer: A,B,D
Rationale: Pyridostigmine should be given with a small amount of food to prevent GI upset, but the client should wait to eat a full meal due to the potential for aspiration. If difficulty with swallowing occurs, the client should seek immediate attention. The dose can change on a day-to-day basis depending on the client's manifestations. Taking the drug on an empty stomach is not necessary, and the client's urine will not turn reddish-orange.
A client has been diagnosed with Bell's palsy. About what drugs should the nurse anticipate possibly teaching? (Select all that apply.)
- A. Acyclovir (Zovirax)
- B. Carbamazepine (Tegretol)
- C. Famciclovir (Famvir)
- D. Prednisone (Deltasone)
- E. Valacyclovir (Valtrex)
Correct Answer: A,C,D,E
Rationale: Possible pharmacologic treatment for Bell's palsy includes acyclovir, famciclovir, prednisone, and valacyclovir. Carbamazepine is an anticonvulsant and mood-stabilizing drug and is not used for Bell's palsy.
An older client is hospitalized with Guillain-Barr?© syndrome. A family member tells the nurse the client is restless and seems confused. What action by the nurse is best?
- A. Assess the client's oxygen saturation
- B. Check the medication list for interactions
- C. Place the client on a bed alarm
- D. Put the client on safety precautions
Correct Answer: A
Rationale: In an older adult, an early sign of hypoxia is often confusion and restlessness. The nurse should first assess the client's oxygen saturation. The other actions are appropriate but only after this assessment occurs.