the nurse formulates a nursing diagnosis of high risk for ineffective airway clearance for a client with myasthenia gravis what is the most likely eti the nurse formulates a nursing diagnosis of high risk for ineffective airway clearance for a client with myasthenia gravis what is the most likely eti
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1. The healthcare provider formulates a nursing diagnosis of 'High risk for ineffective airway clearance' for a client with myasthenia gravis. What is the most likely cause for this nursing diagnosis?

Correct answer: B

Rationale: Clients with myasthenia gravis commonly experience muscle weakness, including in the muscles used for coughing. This diminished cough effort can lead to ineffective airway clearance, increasing the risk of respiratory complications. Therefore, the most likely cause for the nursing diagnosis 'High risk for ineffective airway clearance' in a client with myasthenia gravis is the diminished cough effort due to muscle weakness.

2. A client has a new prescription for furosemide. Which of the following instructions should the nurse include during discharge teaching?

Correct answer: B

Rationale: Monitoring weight daily is crucial when taking furosemide to detect fluid retention or loss. Furosemide is a diuretic that helps the body get rid of excess water and salt through urine. Changes in weight can indicate fluid shifts, which could be a sign of inadequate response to the medication or worsening condition. Therefore, monitoring weight daily is essential to assess the effectiveness of furosemide therapy and detect any potential issues early on. Choices A, C, and D are incorrect. Avoiding foods high in potassium is more relevant for clients taking potassium-sparing diuretics, not furosemide. Taking furosemide with food is not necessary, as it can be taken with or without food. Increasing salt intake is contradictory to the purpose of furosemide, which aims to eliminate excess salt from the body.

3. A nurse is teaching a client who has diabetes mellitus about foot care. Which of the following instructions should the nurse include?

Correct answer: C

Rationale: The correct answer is C: 'Cut toenails straight across.' This instruction is crucial for clients with diabetes to prevent ingrown toenails and potential foot complications. Soaking feet in hot water daily (Choice A) can lead to skin damage and is not recommended for diabetic individuals. Using a heating pad on the feet daily (Choice B) can cause burns or injuries due to reduced sensation in the feet that often accompanies diabetes. Massaging feet with lotion daily (Choice D) is generally safe but may not address the specific preventive measure of cutting toenails correctly.

4. Which of the following interventions is an example of tertiary prevention?

Correct answer: C

Rationale: Tertiary prevention focuses on managing and improving the quality of life for individuals who already have a disease or condition. Physical rehabilitation programs fall under tertiary prevention as they aim to enhance functioning and reduce disability caused by ongoing illness or injury, thus aligning with the goal of tertiary prevention.

5. When demonstrating therapeutic use of self, which nursing intervention is the nurse performing?

Correct answer: A

Rationale: The correct answer is A: Sitting with a dying patient. Therapeutic use of self in nursing involves the nurse's ability to establish a caring and compassionate relationship with patients. Sitting with a dying patient allows the nurse to provide emotional support, physical presence, and comfort, demonstrating the use of self in a therapeutic manner. Choices B, C, and D are incorrect as they do not directly involve the nurse's interaction with a patient in a therapeutic manner.

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