HESI Case Studies–Medical/Surgical-Myasthenia Gravis (Shiri Koradia) – Flashcards
Unlock all answers in this set
Unlock answersquestion
1. Which response to the test indicates that Shiri has myasthenia gravis (MG)?
answer
A noticeably marked improvement in Shiri's muscle strength
question
2. How should the nurse respond?
answer
The body is not able to transmit nerve impulses, which results in muscle weakness
question
3. Which action should the nurse take?
answer
Continue the discussion and answer all of Alum's questions
question
4. How should the nurse respond about the expected outcome of pyridostigmine (Mestinon) therapy?(Select all)
answer
-Increases ability to independently perform activities of daily living (ADLs)-Prevents the breakdown of acetylcholine, a natural substance, in the body
question
5. Which instruction about taking pyridostigmine (Mestinon) should the nurse include in the plan of care?
answer
Take the medication 30 minutes prior to meals
question
6. Which statement(s) indicates to the nurse that Shiri understands the medication teaching? (Select all)
answer
-"I must carry an identification card while on my medication regimen."-"I need to try to take the medication on time."
question
7. Which intervention should the nurse direct toward Alum?
answer
Demonstrate how to perform abdominal thrusts correctly
question
8. Which statement by Shiri indicates she understands the client teaching provided by the nurse?
answer
"I will avoid anyone that has a respiratory infection."
question
9. Which referral to a member of the interdisciplinary team should the nurse make for Shiri?
answer
Speech therapist
question
10. Which further data indicates to the nurse the client is experiencing a cholinergic crisis
answer
The Tensilon test does not show improvement in muscle strength
question
11. In planning care for Shiri, the nurse should identify which diagnosis as a priority?
answer
Ineffective airway clearance
question
12. Which action should the nurse implement first?
answer
Administer intravenous atropine
question
13. What is the best response by the nurse?
answer
"This must be very scary, I will sit with you and we can talk for a while."
question
14. Which action should the nurse take?
answer
Confirm with Shiri that she needs to fast tomorrow
question
15. Which action should the nurse take when they arrive?
answer
Allow Shiri and Alum to see the healthcare provider
question
16. How should the nurse respond?
answer
"There is a gland that is usually inactive after puberty that sometimes continues to produce antibodies. Removing it sometimes cures myasthenia gravis."
question
17. Which intervention should the nurse implement prior to the plasmapheresis?
answer
Assess the complete blood cell and platelet count
question
18. Which part of the assessment indicates to the nurse that Shiri is experiencing a complication from this procedure? (Select all)
answer
-Positive Chvostek's and Trousseau's signs-Elevation of temperature occurs
question
19. Which intervention should the nurse implement?
answer
Monitor for fluctuation or tidaling in the water-seal compartment
question
20. Which intervention should the nurse implement?
answer
Demonstrate how to splint the incision when coughing
question
21. As Shiri is completing her meal request form, the nurse considers Shiri's Hindu culture and anticipates that Shiri will select which meal?
answer
Broccoli rice casserole, salad, and water
question
22. Which action should the nurse implement?
answer
Praise the UAP for making this statement while the client is eating
question
23. Which action should the charge nurse take?
answer
Review the need for two form of identification with the nurse at the medication cart
question
24. What action shuold the nurse implement?
answer
Continue reviewing the discharge instructions with Shiri
question
25. Which statement indicates Shiri understands the instructions provided by the nurse?
answer
"I will call my healthcare provider if I have a temperature of 100.0F or higher."
question
26. Which statement indicates to the nurse that the medication teaching has been effective?
answer
"If I have any weakness or choking episodes I will call my healthcare provider."
