A nurse is providing care to a client with Myasthenia gravis who has lost 6 kg of weight over the past 2 months. What should the nurse suggest to improve this client’s nutritional status?
Restrict drinking fluids before and during meals.
Plan medication doses to occur before meals.
Increase the amount of fat and carbohydrates in meals.
Eat three large meals per day.
The Correct Answer is B
Choice A reason:
Restricting drinking fluids before and during meals is not an appropriate suggestion for improving nutritional status. While it might help prevent early satiety in some cases, it does not address the underlying issues related to Myasthenia gravis, such as muscle weakness affecting chewing and swallowing.
Choice B reason:
Planning medication doses to occur before meals is a crucial strategy for clients with Myasthenia gravis. Medications such as anticholinesterase agents can help improve muscle strength, making it easier for the client to chew and swallow food. This approach can enhance the client’s ability to consume adequate nutrition during meals.
Choice C reason:
Increasing the amount of fat and carbohydrates in meals might help with caloric intake, but it does not address the specific challenges faced by clients with Myasthenia gravis. The focus should be on strategies that improve the client’s ability to eat effectively, rather than just altering the macronutrient composition of meals.
Choice D reason:
Eating three large meals per day can be challenging for clients with Myasthenia gravis due to muscle fatigue. Smaller, more frequent meals are often recommended to help manage energy levels and ensure adequate nutrition without overwhelming the client.
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Correct Answer is B
Explanation
Choice A reason:
Secondary prevention involves early detection and treatment of disease to halt its progression. Examples include screening tests and early interventions. Advising a client with osteoporosis to consume dairy products is not aimed at early detection but rather at preventing the onset of complications by ensuring adequate calcium intake.
Choice B reason:
Primary prevention aims to prevent the onset of disease or injury before it occurs. This includes measures such as vaccinations, lifestyle modifications, and dietary recommendations. Advising a client with osteoporosis to consume three servings of milk or dairy products daily is a primary prevention strategy. It helps to maintain bone density and prevent fractures by ensuring adequate calcium and vitamin D intake.
Choice C reason:
Proactive prevention is not a standard term used in public health or medical practice. The recognized levels of prevention are primary, secondary, and tertiary. Therefore, this option is not applicable in this context.
Choice D reason:
Tertiary prevention focuses on managing and mitigating the effects of an existing disease to prevent further complications and improve quality of life. This includes rehabilitation and ongoing treatment for chronic conditions. While advising a client with osteoporosis to consume dairy products can be part of managing the condition, it is primarily a preventive measure to avoid further bone loss and fractures, aligning more with primary prevention.
Correct Answer is B
Explanation
Choice A reason:
Administering thrombolytics is not the first action the nurse should take. Thrombolytics are used to treat ischemic strokes, but their administration requires a thorough assessment and confirmation of the diagnosis through imaging studies. Immediate action is needed to ensure the client’s safety and initiate the stroke protocol.
Choice B reason:
Calling for help is the first action the nurse should take. The client is exhibiting signs of a possible stroke, and immediate medical intervention is required. Calling for help ensures that the stroke team or emergency response team is activated promptly to provide the necessary care.
Choice C reason:
Providing the client with water to test the gag reflex is not appropriate in this situation. The client may have difficulty swallowing, and giving water could lead to aspiration. The priority is to ensure the client’s safety and initiate the stroke protocol.
Choice D reason:
Performing carotid massage is not indicated for a client with new right-sided weakness and slurred speech. Carotid massage is used to manage certain types of arrhythmias, but it is not appropriate for suspected stroke. The focus should be on immediate assessment and intervention.