MYASTHENIA GRAVIS NCLEX AND ANSWERS
LATEST 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
LATEST 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
