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