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MYASTHENIA GRAVIS NCLEX AND ANSWERS LATEST VERSION VERIFIED RATIONALE GRADED A+
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MYASTHENIA GRAVIS NCLEX AND ANSWERS LATEST VERSION VERIFIED RATIONALE GRADED A+
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MYASTHENIA GRAVIS NCLEX AND ANSWERSLATEST VERSION VERIFIED RATIONALE GRADED
A+
Which statement by the client supports the diagnosis
of myasthenia gravis (MG)?
1. "I have weakness and fa�gue in my feet and legs."
2. "My eyelids droop, and I see double everything."
3. "I get chest pain and faint a�er I walk in the hall."
4. "I gained 3 pounds this week, and I am spi�ng up pink frothy sputum." - ansCorrect answer 2: These
are ocular signs/symptoms
of MG. Ptosis is drooping of the eyelid, and diplopia
is unilateral or bilateral double vision. Weakness and
fa�gue of upper body muscle occur with MG. Op�on
3 is angina. Op�on 4 is heart failure.
The client diagnosed w/ MG is admited w/ an acute exacerba�on. Which interven�ons should the nurse
implement? SELECT ALL APPLY.
A) Assist the pt. to turn and cough every 2 hrs
B) Place client in high/ semi fowlers
C) assess client's pulse ox reading every shi�
D) Plan meals to promote medica�on effec�veness
E) Monitor client's serum an�cholinesterase levels - ansA,B,D
The client diagnosed w/ myasthenia gravis is being discharged home. Which interven�on has priority
when teaching the client's significant others?
A) discuss ways to help prevent choking episodes
B) Explain how to care for a client on a ven�lator
C) Teach how to perform passive ROM exercises
, MYASTHENIA GRAVIS NCLEX AND ANSWERS
LATEST VERSION VERIFIED RATIONALE GRADED
A+
D) Demonstrate how to care for the client's feeding tube - ansA
The client diagnosed with MG is admited to the
emergency department with a sudden exacerba�on of motor weakness. Which assessment data indicate
the client is experiencing a myasthenic crisis?
1. The serum assay of circula�ng acetylcholine
receptor an�bodies is increased.
2. The client's symptoms improve when
administering on a cholinesterase inhibitor.
3. The client's blood pressure, pulse, and respira�ons improve a�er intravenous (IV) fluid.
4. The Tensilon test does not show improvement in the client's muscle strength. - ansCorrect answer 2:
This assessment datum indicates
a myasthenic crisis that is due to undermedica�on,
missed doses of medica�on, or developing an infec�on.
Serum assays are useful in diagnosing the
disease, not in iden�fying a crisis. Vital signs do
not differen�ate the type of crisis. No improvement
a�er Tensilon indicates a cholinergic crisis, not a
myasthenic crisis.
The client diagnosed with MG is being discharged home. Which interven�on should the nurse teach the
significant other?
1. Discuss how to perform the Heimlich maneuver.
2. Explain how to perform oral hygiene on a
conscious client.
3. Teach how to perform isometric exercises. l 4. Demonstrate correct hand placement for chest
compressions. - ansCorrect answer 1: The client is at risk for choking, and knowing specific measures to
help the client helps decrease the client's as well as significant other's anxiety and promotes confidence
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