A nurse is caring for a client with myasthenia gravis who has been prescribed pyridostigmine. Which nursing intervention is most important to include in the care plan for this client?
Monitor for signs of cholinergic crisis, such as excessive salivation and muscle twitching.
Advise the client to discontinue the medication once they experience increased muscle strength.
Encourage the client to take the medication on an empty stomach to enhance absorption.
Teach the client to self-administer pyridostigmine via intramuscular injection.
The Correct Answer is A
Rationale:
A. Pyridostigmine is an acetylcholinesterase inhibitor that increases acetylcholine at neuromuscular junctions to improve muscle strength. However, overmedication can lead to cholinergic crisis, which presents with muscle weakness, excessive salivation, sweating, bradycardia, and gastrointestinal upset. Monitoring for these signs is critical for patient safety and allows for early intervention, such as holding the medication and administering anticholinergic agents (e.g., atropine) if necessary.
B. Pyridostigmine must be taken consistently as prescribed. Stopping the medication abruptly can lead to rebound weakness or myasthenic crisis, which can be life-threatening.
C. While taking pyridostigmine 30–60 minutes before meals can improve absorption and help with swallowing, this is important but not the highest priority intervention. Monitoring for adverse effects takes precedence for patient safety.
D. Pyridostigmine is usually administered orally or intravenously, and self-injection is not standard practice. Teaching injection techniques is unnecessary unless the healthcare provider prescribes an alternative route, which is rare.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Hyperparathyroidism causes elevated parathyroid hormone (PTH) levels, which lead to hypercalcemia. High calcium levels can slow smooth muscle activity in the gastrointestinal tract, resulting in constipation. Other gastrointestinal symptoms may include nausea, vomiting, and abdominal pain, all related to calcium imbalance.
B. While hypercalcemia can cause nonspecific symptoms like fatigue or mild cognitive changes, severe headaches are not a primary manifestation of hyperparathyroidism. Headaches may occur due to other causes but are not diagnostic for this condition.
C. Hyperparathyroidism typically slows GI motility rather than increasing it. Diarrhea is not associated with hypercalcemia; in fact, constipation is more common.
D. Hyperparathyroidism does not directly cause weight gain. Some patients may experience loss of appetite or fatigue due to hypercalcemia, but weight gain is not a characteristic symptom.
Correct Answer is []
Explanation
Rationale:
The client’s report of sharp pain rated 7/10, guarding behavior, and difficulty moving are classic indicators of acute postoperative pain. The slightly elevated temperature and stable incision site suggest inflammation from surgery rather than infection or wound complications.
Administering prescribed IV morphine is appropriate for managing moderate to severe postoperative pain, as opioids act on central nervous system receptors to reduce pain perception. Educating the client on breathing techniques helps prevent complications such as atelectasis and reduces pain associated with movement by promoting relaxation and proper oxygenation.
Monitoring pain level allows evaluation of the effectiveness of analgesic therapy and guides further interventions. Monitoring respiratory rate is essential when administering opioids because of the risk of respiratory depression, ensuring safe and effective pain management.
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