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

Answer and Explanation

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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Correct Answer is B

Explanation

A. Pain complaints are a common issue in skeletal traction and should be managed with appropriate interventions, but they do not warrant the removal of weights.
B. In a life-threatening situation, such as an acute deterioration in the client's condition, it is appropriate to remove the weights to address the emergency and stabilize the patient.
C. X-ray imaging should be coordinated with the traction team, but weights should not be removed solely for diagnostic procedures.
D. Repositioning in bed should be done carefully while maintaining the traction setup; removing weights is not typically required for this purpose.

A. Pain severity B. Wound drainage C. Tissue integrity D. Airway patency

Correct Answer is D

Explanation

A. Pain severity is important to assess but is secondary to ensuring the client's airway is clear and unobstructed.
B. Wound drainage is relevant for detecting potential complications but is not as critical as ensuring airway patency.
C. Tissue integrity is important for wound healing but does not take precedence over checking the airway immediately after surgery.
D. Airway patency is the priority assessment because a partial laryngectomy involves the airway, and ensuring it is open and functioning is crucial for adequate breathing.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who sustained a femur fracture in an automobile accident and is placed into skeletal traction. The nurse may remove the weights from the traction device if which of the following occurs?

Correct Answer is B

Explanation

A nurse is caring for a client who is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?

Correct Answer is D

Explanation

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