The nurse is caring for a client diagnosed with Myasthenia Gravis (MG) who is post op thymectomy. The client problem is Ineffective Breathing Pattern, Which action would the nurse include in the plan of care?

Assess lung sounds and respiratory rate at least every 2 hours

Assess and document pain level once every shift

Maintain sequential compression device (SCD's) while in bed

Elevate the head of the bed ten degrees

Answer and Explanation

The Correct Answer is A

A) Assess lung sounds and respiratory rate at least every 2 hours:
In a patient with Myasthenia Gravis (MG) who has undergone thymectomy, monitoring respiratory status is critical. MG is a neuromuscular disorder that can lead to respiratory muscle weakness, which may be exacerbated post-operatively. Assessing lung sounds and respiratory rate at least every 2 hours is crucial to detect early signs of respiratory compromise, including hypoventilation or atelectasis.

B) Assess and document pain level once every shift:
While pain assessment is important, especially after a thymectomy, this action alone does not directly address the immediate issue of ineffective breathing patterns. In patients with MG, respiratory complications are a priority concern. Pain management should be part of the overall plan of care, but it is secondary to monitoring respiratory function in the acute post-operative period. Pain can affect respiratory effort, but it should be managed in the context of more pressing issues like airway and breathing assessment.

C) Maintain sequential compression device (SCD's) while in bed:
While SCDs are important in preventing deep vein thrombosis (DVT) in patients who are immobile, they are not the most appropriate intervention for a client with ineffective breathing patterns. The primary concern in a post-thymectomy patient with MG is respiratory function.

D) Elevate the head of the bed ten degrees:
While elevating the head of the bed can help with comfort and potentially improve ventilation in some patients, it is not the most specific or effective intervention for managing ineffective breathing patterns in a patient with MG. For optimal respiratory function, it is typically more beneficial to elevate the head of the bed to a higher degree (e.g., 30-45 degrees) to enhance lung expansion, rather than just 10 degrees.

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Correct Answer is B

Explanation

A) Notify the primary care provider with increased urine output
Increased urine output is not directly related to signs or symptoms of infection associated with a tunneled IV catheter, such as a Hickman catheter. While changes in urinary output might indicate renal or other systemic issues, they do not signal a local infection at the insertion site.

B) Assess daily for redness, swelling, or exudate at insertion site weekly
One of the most common complications of a tunneled IV catheter, such as a Hickman, is infection at the insertion site or along the catheter tract. The nurse should instruct the patient to monitor for signs of infection, including redness, swelling, and exudate (pus or drainage) at the insertion site. These signs suggest possible infection, and early detection is critical to preventing more serious complications like sepsis.

C) The primary care provider will monitor hemoglobin and hematocrit values
While monitoring hemoglobin and hematocrit values is important for assessing overall health and blood status, it is not specifically related to monitoring for infection in a client with a tunneled IV catheter. Hemoglobin and hematocrit can provide information about anemia or dehydration but do not directly indicate an infection at the insertion site.

D) To maintain patency, the catheter should be flushed weekly using a 5ml syringe
Although flushing a tunneled IV catheter to maintain patency is important, this response does not directly address infection prevention, which is the focus of the question. Typically, a catheter should be flushed as per specific guidelines (which may include daily or weekly flushing, depending on the clinical setting).

A. “I will be able to recall events from childhood after completing rehabilitation B. "I will display all of my preinjury traits and characteristics. C. I will regain complete motor and sensory functions after rehabilitation D. I should actively participate in the rehabilitation process as appropriate

Correct Answer is D

Explanation

A) “I will be able to recall events from childhood after completing rehabilitation”:
This demonstrates an unrealistic expectation. While rehabilitation can significantly improve cognitive functions, a serious brain injury may affect memory and recall to a degree that may not be fully reversible. Complete recovery of specific memories, such as childhood events, is not guaranteed.

B) "I will display all of my pre-injury traits and characteristics.":
This also reflects an unrealistic goal. Brain injuries can result in permanent changes to cognitive, emotional, and physical functioning. While rehabilitation can help a patient regain many abilities, it is unlikely that they will fully return to their pre-injury state, particularly in terms of personality traits and behaviors.

C) “I will regain complete motor and sensory functions after rehabilitation”:
This is also unrealistic. While rehabilitation aims to help patients regain as much motor and sensory function as possible, it is often not possible to fully restore complete function after a significant brain injury. Recovery may be partial, and some deficits may remain, depending on the extent of the injury.

D) “I should actively participate in the rehabilitation process as appropriate”:
This reflects a realistic and positive approach to recovery. Active participation in rehabilitation is essential for maximizing recovery after a brain injury. The process involves setting attainable goals based on the patient’s current abilities and gradually working toward improving those functions.

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The nurse is caring for a client diagnosed with Myasthenia Gravis (MG) who is post op thymectomy. The client problem is Ineffective Breathing Pattern, Which action would the nurse include in the plan of care?

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