A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following interventions should the nurse take?

Administer an anticholinesterase medication.

Instruct the client to perform the pursed lip breathing.

Prepare to administer a vasoconstrictor.

Prepare the client for mechanical ventilation.

Answer and Explanation

The Correct Answer is D

Choice A reason:

Administering an anticholinesterase medication is not the primary intervention during a myasthenic crisis. While these medications can improve muscle strength in myasthenia gravis, they are not sufficient in the event of a crisis.

Choice B reason:

Pursed lip breathing is a technique used to manage dyspnea but is not adequate for the acute management of a myasthenic crisis, which can involve respiratory muscle paralysis.

Choice C reason:

Vasoconstrictors are not used in the treatment of myasthenic crisis. This condition is not related to vascular issues but to neuromuscular transmission failure leading to respiratory failure.

Choice D reason:

Mechanical ventilation is the correct intervention as it provides the necessary respiratory support when the patient's respiratory muscles are too weak to maintain adequate ventilation.

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Correct Answer is D

Explanation

Moving objects away from the client is an important action to take during a seizure, as it can prevent injury and protect the client from harm.

"Place the client on his back." is not correct, as it can cause airway obstruction and aspiration. The client should be placed on his side, preferably in a lateral recumbent position, to allow saliva and secretions to drain from the mouth.

"Restrain the client." is not appropriate, as it can cause injury, increase agitation, or prolong the seizure. The client should be allowed to move freely during a seizure, but supported and guided away from hazards.

"Insert a padded tongue blade into the client's mouth." is not advisable, as it can cause oral trauma, choking, or damage to the teeth. The client should not have anything inserted into his mouth during a seizure, as he cannot swallow or bite his tongue. The nurse should ensure that the client's airway is clear and patent.

A. Take 1 capsule at the onset of anginal pain. B. Take the medication with meals. C. Swallow the capsules whole. D. Stop taking the medication if side eﬀects are troublesome.

Correct Answer is C

Explanation

Swallowing the capsules whole is the correct way to take nitroglycerin oral, sustained-release capsules, as they are designed to release the medication slowly and steadily over time. The client should not crush, chew, or open the capsules, as this can alter the absorption and eﬀectiveness of the medication.

Taking 1 capsule at the onset of anginal pain is not appropriate, as nitroglycerin oral, sustained-release capsules are not meant for acute episodes of angina, but for long-term prevention and management. The client should use a fast-acting form of nitroglycerin, such as sublingual tablets or spray, to relieve anginal pain.

Taking the medication with meals is not necessary, as nitroglycerin oral, sustained-release capsules can be taken with or without food. However, the client should take the medication at regular intervals and around the same time each day.

Stopping taking the medication if side eﬀects are troublesome is not advisable, as nitroglycerin oral, sustained-release capsules can cause withdrawal symptoms and rebound angina if discontinued abruptly. The client should consult with the provider before stopping or changing the dose of the medication. The client should also report any severe or persistent side eﬀects, such as headache, dizziness, hypotension, or tachycardia.

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A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following interventions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

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