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 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.
Correct Answer is B
Explanation
Choice a reason:
A negative-pressure isolation room is designed to prevent the spread of airborne infectious diseases by ensuring that air flows into the room but not out of it. This type of room is typically used for patients with diseases such as tuberculosis, measles, or COVID-19, which are spread through airborne particles. Scabies, however, is spread through direct skin-to-skin contact or by sharing personal items like bedding or clothing. Therefore, a negative-pressure isolation room is not necessary for a patient with scabies, as the primary mode of transmission is not airborne.
Choice b reason:
A private room is the most appropriate setting for a client with scabies. Scabies is highly contagious and can spread through direct skin-to-skin contact or by sharing personal items. Placing the client in a private room helps to prevent the spread of the mites to other patients and staff. In a private room, the client can be isolated effectively, and healthcare workers can implement contact precautions, such as wearing gloves and gowns, to minimize the risk of transmission. This approach ensures that the client receives appropriate care while protecting others from potential exposure.
Choice c reason:
A semi-private room with a client who has pediculosis capitis (head lice) is not suitable for a client with scabies. Although both conditions involve infestations, they are caused by different parasites and have different modes of transmission. Pediculosis capitis is spread through direct contact with infested hair or personal items, while scabies is spread through prolonged skin-to-skin contact. Placing a client with scabies in a semi-private room with another infested patient increases the risk of cross-contamination and further spread of both conditions. Therefore, this option is not recommended.
Choice d reason:
A positive-pressure isolation room is designed to protect immunocompromised patients from airborne pathogens by ensuring that air flows out of the room but not into it. This type of room is used for patients who need to be protected from infections, such as those undergoing chemotherapy or with severe immune deficiencies. Since scabies is not an airborne disease and does not pose a risk to immunocompromised patients in this manner, a positive-pressure isolation room is not appropriate for a client with scabies. The primary concern with scabies is preventing direct contact transmission, which is best managed in a private room.