The nurse identifies a nursing diagnosis of Diarrhea for a client ...

[justinmsk]

The nurse identifies a nursing diagnosis of Diarrhea for a client being started on cholinergic drug therapy. Which of the following would the nurse most likely include in the client's plan of care? Select all that apply.
 
  A) Ensure that the client has readily available access to the bathroom.
  B) Evaluate the number, frequency, and consistency of the stools.
  C) Contact the primary health care provider for an order to switch to another cholinergic drug.
  D) Limit the client's fluid intake to 1000 mL per day.
  E) Maintain the client on strict bed rest.

Question 2

A nurse is caring for a client with myasthenia gravis at a health care facility. The client is receiving ambenonium. The nurse suspects that the dosage is insufficient based on assessment of which of the following?
 
  A) Clenching of the jaw
  B) Muscle spasms
  C) Difficulty breathing
  D) Abdominal cramping

[brbarasa]

Answer to Question 1

Ans: A, B
Feedback:
When a cholinergic drug is administered, the client may experience diarrhea. This reaction will continue until tolerance develops, usually within a few weeks. Until tolerance develops, the nurse needs to ensure that proper facilities, such as a bedside commode, bedpan, or bathroom, are readily available. The patient is encouraged to ambulate to assist in the passing of flatus. If needed, a rectal tube may be used to assist in the passing of flatus. The nurse should document fluid intake and output and track the number, consistency, and frequency of stools if diarrhea is present. Since diarrhea occurs with any cholinergic drug, switching to another would be of no help. The client needs to replace fluids lost with diarrhea, so limiting fluid intake would be inappropriate. Ambulating to assist with the passage of flatus would be appropriate, while strict bed rest would not be necessary.

Answer to Question 2

Ans: C
Feedback:
The nurse should monitor for difficulty breathing as a symptom of drug underdosage. Clenching of the jaw and muscle spasms are symptoms of drug overdosage. Abdominal cramping may occur in the client who is receiving guanidine.

[justinmsk]

Both answers were spot on, thank you once again

[brbarasa]

Great! Please up vote