A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?
Confusion
Increased urinary output
Increased intracranial pressure
Weakness
The Correct Answer is D
A. Confusion is not a typical manifestation of myasthenia gravis but could be related to other issues or conditions.
B. Increased urinary output is not directly associated with myasthenia gravis and is not a primary symptom to monitor.
C. Increased intracranial pressure is not characteristic of myasthenia gravis and is unrelated to the condition.
D. Weakness is a hallmark symptom of myasthenia gravis, resulting from impaired communication between nerves and muscles. It is crucial to monitor and assess for changes in muscle strength and fatigue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A WBC count of 1500/mm3 is significantly low (normal range is 4500-11000/mm3) and indicates neutropenia, placing the client at high risk for infection. This finding should be reported to the provider immediately.
B. An RBC count of 5 million/mm3 is within the normal range for females (4.2-5.4 million/mm3) and does not indicate an immediate concern in the context of chemotherapy.
C. Platelet count of 155,000/mm3 is on the lower end of the normal range (150,000-450,000/mm3) but does not pose an immediate risk compared to neutropenia.
D. A hemoglobin level of 12 g/dL is within the normal range for females (12-16 g/dL) and does not require urgent reporting.
Correct Answer is B
Explanation
A. A decrease in urinary output can be a sign of decreased blood volume but is less immediate than changes in heart rate.
B. An increase in the heart rate is a common compensatory response to hypovolemia as the body attempts to maintain adequate perfusion to vital organs.
C. A decrease in the respiratory rate is not typically associated with hypovolemic shock; rather, respiratory rate may increase due to compensatory mechanisms.
D. An increase in temperature is not a specific indicator of hypovolemic shock; it could be related to infection or inflammation rather than immediate hypovolemia.
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