The nurse is teaching a patient with myasthenia gravis how to prevent a myasthenic crisis.
What topic is most important to include?
Wear gloves when handling frozen food items.
Avoid warm climates.
Receive an annual influenza vaccination.
Increase intake of protein.
The Correct Answer is C
Choice A rationale
Wearing gloves when handling frozen food items is not related to preventing a myasthenic crisis. A myasthenic crisis is characterized by severe muscle weakness, including respiratory muscles, and is often triggered by infection or medication changes, not temperature exposure to hands.
Choice B rationale
Avoiding warm climates is not a primary preventative measure for myasthenic crisis. While extreme temperatures can sometimes exacerbate symptoms in some individuals with myasthenia gravis, it is not a direct trigger for a crisis. Infections are a far more common precipitating factor.
Choice C rationale
Receiving an annual influenza vaccination is crucial for preventing infections, which are a common trigger for myasthenic crisis. Infections, particularly respiratory infections, can significantly worsen muscle weakness and precipitate life-threatening respiratory compromise in patients with myasthenia gravis.
Choice D rationale
Increasing intake of protein does not directly prevent a myasthenic crisis. While adequate nutrition is important for overall health, there is no specific evidence that increased protein intake prevents the acute exacerbation of muscle weakness characteristic of a myasthenic crisis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale
Measurement of post-void residual (PVR) urine volume is a valid indication for catheterization. This procedure assesses bladder emptying efficiency, particularly in patients experiencing urinary symptoms like hesitancy or incomplete voiding. Elevated PVR volumes (typically > 100 mL) can indicate outflow obstruction or bladder dysfunction, necessitating further investigation.
Choice B rationale
Relief of urinary retention is a primary indication for catheterization. Acute urinary retention, often caused by prostatic enlargement or neurologic dysfunction, results in painful bladder distention and potential renal compromise. Catheterization promptly drains the bladder, alleviating discomfort and preventing upper urinary tract damage by reducing intravesical pressure.
Choice C rationale
Routine acquisition of a urine specimen is generally not an indication for catheterization. Clean-catch midstream urine samples are typically sufficient for most diagnostic purposes, minimizing the risk of catheter-associated urinary tract infections (CAUTIs). Catheterization is invasive and should be reserved for situations where a clean voided specimen is unobtainable or specific sterile collection is required.
Choice D rationale
Convenience for nursing staff or the patient's family is not a legitimate medical indication for urinary catheterization. Catheterization is an invasive procedure associated with significant risks, including CAUTIs, urethral trauma, and patient discomfort. Its use should be medically justified and limited to situations where benefits clearly outweigh the potential harms, prioritizing patient safety.
Choice E rationale
An open perineal wound is a strong indication for urinary catheterization. Catheterization diverts urine away from the wound, preventing contamination and promoting optimal healing. Urine is inherently acidic and can introduce bacteria, impairing tissue repair and increasing infection risk in compromised perineal tissues, making diversion crucial for wound management.
Correct Answer is C
Explanation
Choice A rationale
Identifying renal artery bruits typically involves auscultation, not palpation. Bruits are abnormal sounds produced by turbulent blood flow through a narrowed or constricted artery, which are heard with a stethoscope placed over the renal arteries. Palpation is not an effective method for detecting vascular sounds.
Choice B rationale
Assessing for ureteral peristalsis is challenging and not routinely done through external palpation. Ureteral peristalsis involves rhythmic contractions of the smooth muscle in the ureters that propel urine from the kidneys to the bladder, which is an internal physiological process not directly palpable through the abdominal wall.
Choice C rationale
Palpation is a standard physical assessment technique used to detect bladder distention. An overfilled bladder rises above the symphysis pubis and can be felt as a firm, rounded mass in the suprapubic area, indicating urinary retention or incomplete emptying, which is a common post-catheter removal assessment.
Choice D rationale
Determining kidney function primarily involves laboratory tests, such as serum creatinine, blood urea nitrogen (BUN), and glomerular filtration rate (GFR) calculations, rather than physical palpation. While kidney palpation can assess size and tenderness, it does not directly measure the physiological efficiency of filtration and waste removal.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.