A client with myasthenia gravis receives a new prescription for pyridostigmine. Which information should the nurse obtain prior to administering the medication?
Trouble sleeping
Difficulty with urination
Unexplained weight loss
Recent oral intake
The Correct Answer is D
Choice A reason: Trouble sleeping is not a relevant information for administering pyridostigmine, which is a cholinesterase inhibitor that improves muscle strength and function in patients with myasthenia gravis. Trouble sleeping may be caused by other factors, such as stress, pain, or medication side effects.
Choice B reason: Difficulty with urination is not a pertinent information for administering pyridostigmine, which does not affect urinary function or bladder control. Difficulty with urination may indicate a urinary tract infection, prostate enlargement, or kidney stones.
Choice C reason: Unexplained weight loss is not a significant information for administering pyridostigmine, which does not affect metabolism or appetite. Unexplained weight loss may be a sign of an underlying condition, such as hyperthyroidism, diabetes, or cancer.
Choice D reason: Recent oral intake is the correct information for administering pyridostigmine, which should be taken on an empty stomach or before meals to enhance its absorption and effectiveness. Pyridostigmine can also help prevent or reduce dysphagia (difficulty swallowing), which is a common symptom of myasthenia gravis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Midmorning is not a likely time for experiencing hypoglycemia after administering glargine insulin at 0800, because glargine insulin has a slow onset of action (about 1 hour) and does not have a pronounced peak effect. Glargine insulin is a long-acting insulin that provides a steady level of insulin throughout the day and night.
Choice B reason: No peak occurs is the correct answer for when hypoglycemia is most likely to occur after administering glargine insulin at 0800, because glargine insulin does not have a pronounced peak effect that could cause a sudden drop in blood glucose levels. Glargine insulin is a long-acting insulin that provides a steady level of insulin throughout the day and night.
Choice C reason: Midafternoon is not a likely time for experiencing hypoglycemia after administering glargine insulin at 0800, because glargine insulin has a long duration of action (about 24 hours) and does not have a pronounced peak effect. Glargine insulin is a long-acting insulin that provides a steady level of insulin throughout the day and night.
Choice D reason: Shortly after midnight is not a likely time for experiencing hypoglycemia after administering glargine insulin at 0800, because glargine insulin has a long duration of action (about 24 hours) and does not have a pronounced peak effect. Glargine insulin is a long-acting insulin that provides a steady level of insulin throughout the day and night.
Correct Answer is ["B","C","D"]
Explanation
Choice A reason:
Seizures are not a common side effect of morphine, and they are unlikely to contribute to this client's fall risk. Seizures can occur in rare cases of morphine overdose, hypersensitivity, or withdrawal, but they are not expected in a client who is receiving a continuous and monitored dose of morphine. Therefore, choice A is incorrect.
Choice B reason:
Nausea is a common side effect of morphine, and it can contribute to this client's fall risk. Nausea can cause the client to feel dizzy, weak, or unsteady, and it can also impair the client's appetite and hydration status. Nausea can also trigger vomiting, which can increase the risk of aspiration or dehydration. Therefore, choice B is correct.
Choice C reason:
Orthostatic hypotension is a common side effect of morphine, and it can contribute to this client's fall risk. Orthostatic hypotension is a sudden drop in blood pressure that occurs when the client changes position from lying to sitting or standing. Orthostatic hypotension can cause the client to feel faint, dizzy, or lightheaded, and it can also increase the risk of syncope (loss of consciousness) or cardiac arrhythmias. Therefore, choice C is correct.
Choice D reason:
Sedation is a common side effect of morphine, and it can contribute to this client's fall risk. Sedation can cause the client to feel sleepy, drowsy, or confused, and it can also impair the client's alertness and coordination. Sedation can also reduce the client's ability to respond to stimuli or alarms, and it can increase the risk of respiratory depression or coma. Therefore, choice D is correct.
Choice E reason:
Euphoria is a common side effect of morphine, and it can contribute to this client's fall risk. Euphoria is a feeling of intense happiness or well-being that is induced by the activation of opioid receptors in the brain. Euphoria can cause the client to feel overconfident, impulsive, or reckless, and it can also impair the client's judgment and perception of reality. Euphoria can also increase the risk of psychological dependence or addiction. Therefore, choice E is correct.
Choice F reason:
Itching is a common side effect of morphine, and it can contribute to this client's fall risk. Itching is caused by the release of histamine from mast cells in response to the stimulation of opioid receptors in the skin. Itching can cause the client to scratch excessively, which can damage the skin and increase the risk of infection. Itching can also distract the client from other sensations or warnings, and it can reduce the client's comfort and quality of life. Therefore, choice F is correct.
Choice G reason:
Urinary retention is a common side effect of morphine, and it can contribute to this client's fall risk. Urinary retention is the inability to empty the bladder completely or voluntarily due to the inhibition of bladder contraction by opioid receptors in the urinary tract. Urinary retention can cause the client to feel pain, discomfort, or urgency in the lower abdomen, and it can also increase the risk of urinary tract infection or kidney damage. Urinary retention can also prompt the client to attempt to get out of bed without assistance or supervision, which can increase the risk of falling. Therefore, choice G is correct.
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