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:
“It is a test that determines which activities you feel most comfortable performing” is not entirely accurate. While comfort with activities may be assessed, the primary goal of a functional assessment is to evaluate the client’s ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs).
Choice B reason:
“It is a tool that is used to determine your maximum level of self-sufficiency.” This response accurately reflects the purpose of a functional assessment. The assessment evaluates the client’s ability to perform ADLs and IADLs independently, which helps determine the level of assistance they may need.
Choice C reason:
“It is a tool that is used to assess what services you will need a home health aide to perform for you” is partially correct but not comprehensive. While the assessment can help identify the need for home health aide services, its primary purpose is to evaluate overall self-sufficiency and functional status.
Choice D reason:
“It is a tool used by insurance companies to determine qualifications for medical reimbursement” is not the primary purpose of a functional assessment. Although the results may be used for insurance purposes, the main goal is to assess the client’s functional abilities and needs.
Correct Answer is ["C","D","E"]
Explanation
Choice A reason:
Going automatically into the client’s bedroom without permission is inappropriate and can be seen as an invasion of privacy. The nurse should always seek consent and respect the client’s personal space. Building trust and maintaining professional boundaries are crucial in home care settings.
Choice B reason:
While it is courteous to thank the client for arranging a home visit, it is not a critical action that directly impacts the care provided. The focus should be on assessing the client’s needs and establishing a care plan.
Choice C reason:
Arranging mutual future visits is an appropriate action. It helps to establish a consistent care schedule, ensuring that the client receives ongoing support and monitoring. This is particularly important for managing chronic conditions like diabetes, where regular follow-up is essential for effective management.
Choice D reason:
Asking how the client is managing at home is a crucial part of the initial assessment. It provides the nurse with valuable information about the client’s current health status, challenges, and needs. This information is essential for developing a personalized care plan that addresses the client’s specific circumstances.
Choice E reason:
Sitting down and discussing with the client and family members is an important step in the initial home care visit. It helps to build rapport, understand the client’s support system, and involve family members in the care process. This collaborative approach ensures that everyone is informed and can contribute to the client’s care and well-being.