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.
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Related Questions
Correct Answer is C
Explanation
A. Urinary output is important but secondary to respiratory concerns in this postoperative context.
B. Arterial blood gases provide valuable information but are less immediate compared to issues directly affecting lung function.
C. Chest tube drainage is critical to monitor for complications such as pneumothorax or hemothorax, which are significant concerns post-thoracotomy and lobectomy.
D. Pain level is important for patient comfort but does not have the immediate impact on recovery compared to chest tube drainage.
Correct Answer is C
Explanation
A. A self-report pain rating scale is not effective for clients with expressive aphasia as they may have difficulty communicating verbally. Alternative methods are needed to assess pain in these clients.
B. Scheduled treatments and client illness are not direct methods for assessing pain levels. They provide context but do not directly measure pain.
C. Behavioral indicators and effect are crucial for assessing pain in clients with expressive aphasia. Observing changes in behavior and facial expressions can help identify discomfort when verbal communication is not possible.
D. Pulse and blood pressure findings can be influenced by pain but are not specific indicators of pain level. Behavioral observations are more direct and reliable in clients with communication difficulties.
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