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 A
Explanation
Choice A: Red tag
A red tag is assigned to patients who require immediate medical attention and intervention to survive. These patients have life-threatening injuries but have a high chance of survival if treated promptly. In this scenario, the client has a respiratory rate of 38, a weak and rapid pulse, and uncontrolled bleeding. These symptoms indicate severe physiological distress and potential shock, necessitating immediate intervention to prevent death. According to NATO triage guidelines, such critical conditions warrant a red tag to prioritize urgent care1.
Choice B: Black tag
A black tag is used for patients who are deceased or have injuries so severe that survival is unlikely even with immediate medical intervention. This category is also known as “expectant” and is used to allocate resources to those with a higher chance of survival. The client in this scenario, despite having severe symptoms, is not described as being beyond the possibility of survival, thus a black tag would not be appropriate1.
Choice C: Green tag
A green tag is assigned to patients with minor injuries who can wait for medical treatment without immediate risk to life. These patients are often referred to as “walking wounded.” The client’s symptoms of a high respiratory rate, weak and rapid pulse, and uncontrolled bleeding are far too severe to be classified under this category. Assigning a green tag would delay critical care, potentially leading to fatal outcomes1.
Choice D: Yellow tag
A yellow tag is for patients who have serious injuries but whose treatment can be delayed without immediate risk to life. These patients need medical attention but are stable enough to wait for a short period. Given the client’s symptoms, particularly the uncontrolled bleeding and signs of shock, delaying treatment could result in rapid deterioration. Therefore, a yellow tag would not be suitable in this case1.