A nurse is caring for a client who has myasthenia gravis. Which of the following actions should the nurse take?
Instruct the client to take prescribed anticholinesterase with meals
Position the head of the client's bed to 40° while eating
Encourage the client to lie down after eating
Provide the client with food cut into small bites
The Correct Answer is B
Choice A reason: Anticholinesterase medications should be taken 30 minutes before meals, not with meals. This is because they enhance the action of acetylcholine, which improves muscle strength and swallowing ability.
Choice B reason: Positioning the head of the client's bed to 40° while eating helps prevent aspiration and facilitates swallowing. This is the best action for the nurse to take for a client who has myasthenia gravis.
Choice C reason: Encouraging the client to lie down after eating is not advisable, as it increases the risk of aspiration and reflux. The client should remain upright for at least 30 minutes after eating.
Choice D reason: Providing the client with food cut into small bites is not enough to ensure safe and adequate nutrition. The client may still have difficulty swallowing and chewing. The nurse should also offer soft, moist, and easy-to-swallow foods, and avoid foods that are dry, sticky, or hard.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Choice A reason: Nuts are not a complete protein, as they are low in the essential amino acid lysine¹. However, nuts can be combined with other plant-based foods, such as grains or legumes, to form a complete protein.
Choice B reason: Eggs are a complete protein, as they contain all nine essential amino acids in adequate amounts². Eggs are also a good source of protein, with about 6 grams per egg³.
Choice C reason: Poultry, such as chicken, turkey, or duck, is a complete protein, as it contains all nine essential amino acids in sufficient amounts⁴. Poultry is also a lean source of protein, with about 25 grams per 3-ounce serving.
Choice D reason: Legumes, such as beans, peas, or lentils, are not a complete protein, as they are low in the essential amino acid methionine. However, legumes can be combined with other plant-based foods, such as grains or nuts, to form a complete protein.
Choice E reason: Grains, such as wheat, rice, or oats, are not a complete protein, as they are low in the essential amino acid lysine. However, grains can be combined with other plant-based foods, such as legumes or nuts, to form a complete protein.
Correct Answer is B
Explanation
Choice A reason: Changing the feeding to a continuous infusion may not improve the constipation, as it does not address the fluid deficit or the fiber content of the formula. Continuous infusion may also increase the risk of aspiration, diarrhea, and bacterial contamination¹.
Choice B reason: Increasing the amount of free water can help prevent or treat constipation by hydrating the stool and facilitating its passage. The client's fluid intake and output indicate a fluid deficit, which can contribute to constipation. The recommended fluid intake for adults is 30 to 35 mL/kg/day².
Choice C reason: Decreasing the infusion rate of feeding may worsen the constipation, as it reduces the caloric and fluid intake of the client. The infusion rate should be based on the client's nutritional needs and tolerance¹.
Choice D reason: Requesting a prescription for a diuretic is not appropriate, as it would further dehydrate the client and aggravate the constipation. Diuretics are indicated for clients with fluid overload, not fluid deficit³.
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