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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Aphasia is a language disorder that affects the ability to understand or produce speech. It can be caused by damage to the brain regions that control language, such as from a stroke. Depending on the type and severity of aphasia, the client may have difficulty with comprehension, expression, reading, or writing. Communication strategies for clients with aphasia include using nonverbal cues, such as gestures, facial expressions, pictures, or objects, to supplement verbal messages and enhance understanding.
The other options are not correct because:
a. "Use simple, childlike statements when speaking." This statement is incorrect because it is patronizing and disrespectful to the client. The client's cognitive and intellectual abilities are not affected by aphasia, only their language skills. The nurse should use simple and clear sentences, but not childish or demeaning ones.
c. "Use a higher-pitched tone of voice when speaking." This statement is incorrect because it is unnecessary and may be irritating to the client. The client's hearing is not affected by aphasia, only their language processing. The nurse should use a normal tone of voice and speak slowly and clearly.
d. "Ask multiple choice questions as part of the conversation." This statement is incorrect because it may be confusing and frustrating to the client. The client may have difficulty with verbal output or comprehension, and
multiple choice questions may add to their cognitive load. The nurse should ask yes or no questions or use gestures or pictures to elicit responses from the client.
Correct Answer is ["50"]
Explanation
To calculate the gt/min, the nurse should use the following formula:
gt/min = (mL/hr x drop factor) / 60
Plugging in the given values, we get:
gt/min = (150 mL/hr x 20 gt/mL) / 60
gt/min = 3000 gt/hr / 60 gt/min = 50 gt/min
Therefore, the nurse should set the manual IV infusion to deliver 50 gt/min.
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