A client with myasthenia gravis receives a now prescription for pyridostigmine. Which information should the nurse obtain to prior to administering the medication?

Recent oral intake.

Trouble sleeping.

Unexplained weight loss.

Difficulty with urination.

Answer and Explanation

The Correct Answer is A

A) Recent oral intake: This information is important because pyridostigmine is typically administered orally and can interact with food, affecting its absorption. It is essential to ensure that the client has recently eaten or will eat soon to minimize gastrointestinal side effects and optimize medication absorption.

B) Trouble sleeping: While sleep disturbances can be a concern, particularly if they worsen with medication use, it may not be the most critical information to obtain before administering pyridostigmine. However, if the client experiences worsening sleep disturbances after starting the medication, it should be reported to the healthcare provider.

C) Unexplained weight loss: While weight loss can be a symptom of myasthenia gravis, it may not be directly related to the administration of pyridostigmine. However, if the client experiences significant weight loss or other unexplained symptoms, further assessment and evaluation may be necessary.

D) Difficulty with urination: Pyridostigmine can affect bladder function and may exacerbate urinary retention, especially in clients with myasthenia gravis. However, obtaining information about the client's recent oral intake is more crucial to ensure optimal medication absorption and minimize gastrointestinal side effects. Difficulty with urination should still be monitored, but it may not be the most immediate concern before administering the medication.

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Correct Answer is D

Explanation

A) Sensitivity to the sun can develop: St. John's wo’t can increase photosensitivity, making the skin more prone to sunburn. Therefore, clients should be advised to use sunscreen and protective clothing when exposed to sunlight.

B) Hard candy can be used for a dry mouth: Dry mouth is a common side effect of St. John's wo’t. Suggesting the use of hard candy can help alleviate the discomfort associated with dry mouth by stimulating saliva production.

C) Insomnia may occur while taking the medication: St. John's wo’t may cause insomnia or exacerbate existing sleep disturbances. Clients should be informed about this potential side effect so they can monitor their sleep patterns and seek appropriate management if needed.

D) Another form of contraception is not needed: This statement requires further instruction. St. John's wo’t can decrease the effectiveness of hormonal contraceptives, including birth control pills, patches, and rings. Therefore, clients using hormonal contraceptives should be advised to use additional or alternative methods of contraception to prevent unintended pregnancy.

A. Assess for orthostatic hypotension before administering the dose. B. Administer the dose and monitor the client's blood pressure regularly. C. Withhold the scheduled dose and notify the healthcare provider. D. Apply a telemetry monitor before administering the dose.

Correct Answer is C

Explanation

A) Assessing for orthostatic hypotension is important when administering medications that can lower blood pressure, but in this scenario, the vital signs indicate bradycardia (heart rate of 48 beats/minute), which may be a contraindication for administering labetalol. Therefore, withholding the dose and notifying the healthcare provider is the priority.

B) Administering the dose and monitoring the client's blood pressure regularly could potentially worsen bradycardia and hypotension, especially given the client's current vital signs. It is safer to withhold the dose and seek guidance from the healthcare provider.

C) Withholding the scheduled dose and notifying the healthcare provider is the most appropriate action in this situation. The client's bradycardia, along with the hypertension, raises concern about the safety of administering labetalol without further assessment and possible adjustment of the treatment plan.

D) Applying a telemetry monitor may be warranted if the client's bradycardia is of concern, but it does not address the potential risk associated with administering labetalol to a client with a heart rate of 48 beats/minute. The priority is to withhold the medication and inform the healthcare provider for further evaluation and guidance.

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A client with myasthenia gravis receives a now prescription for pyridostigmine. Which information should the nurse obtain to prior to administering the medication?

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