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 C

Explanation

Obtaining a pair of slipper socks for the client is a simple and safe way to provide warmth and insulation to the feet, which can improve blood ﬂow and comfort.

Placing a moist heating pad under the client's feet is not recommended, as it can cause burns, vasodilation, or increased ﬂuid loss, which can worsen the condition.

Increasing the client's oral ﬂuid intake is not relevant, as it does not aﬀect the temperature or circulation of the feet.

Rubbing the client's feet briskly for several minutes is not advisable, as it can cause trauma, inﬂammation, or ulceration to the fragile skin and tissues of the feet.

Obtaining a pair of slipper socks for the client is a simple and safe way to provide warmth and insulation to the feet, which can improve blood ﬂow and comfort.

Placing a moist heating pad under the client's feet is not recommended, as it can cause burns, vasodilation, or increased ﬂuid loss, which can worsen the condition.

Increasing the client's oral ﬂuid intake is not relevant, as it does not aﬀect the temperature or circulation of the feet.

Rubbing the client's feet briskly for several minutes is not advisable, as it can cause trauma, inﬂammation, or ulceration to the fragile skin and tissues of the feet.

A. "I should use naproxen to manage discomfort." B. "I plan to slow down if I am tired the day after exercising." C. "I will read food labels and limit my sodium to 4 grams per day." D. "I will take my diuretic before sleep and drink ﬂuids during the day."

Correct Answer is B

Explanation

Planning to slow down if tired the day after exercising is a statement that indicates the client understands the importance of pacing activities and avoiding overexertion, which can worsen heart failure symptoms.

a. "I should use naproxen to manage discomfort." is not correct, as naproxen is a nonsteroidal anti-inﬂammatory drug (NSAID) that can cause ﬂuid retention, increase blood pressure, and worsen heart failure. The client should avoid NSAIDs and use other analgesics, such as acetaminophen, unless contraindicated.

c. "I will read food labels and limit my sodium to 4 grams per day." is not appropriate, as 4 grams of sodium per day is too high for a client who has congestive heart failure. The client should limit sodium intake to 2 grams or less per day, as sodium can cause ﬂuid retention and increase the workload of the heart.

d. "I will take my diuretic before sleep and drink ﬂuids during the day." is not advisable, as taking a diuretic before sleep can cause nocturia and disrupt the sleep cycle, which can aﬀect the quality of life and cardiac function. The

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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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