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 D
Explanation
Taking one tablet at the first indication of chest pain is the correct way to use SL nitroglycerin tablets, as they are fast- acting and can relieve anginal symptoms within minutes. The client should place the tablet under the tongue and let it dissolve.
Taking one tablet at the first indication of chest pain is the correct way to use SL nitroglycerin tablets, as they are fast- acting and can relieve anginal symptoms within minutes. The client should place the tablet under the tongue and let it dissolve.
Taking this medication after each meal and at bedtime is not appropriate, as SL nitroglycerin tablets are not meant for routine or prophylactic use, but only for acute episodes of angina.
Taking one tablet every 15 min during an acute attack is not correct, as the client should not exceed three doses in 15 min. If the pain is not relieved after three doses, the client should seek emergency medical attention.
Taking this medication with 8 ounces of water is not necessary, as SL nitroglycerin tablets do not need to be swallowed or washed down with water. They should be dissolved under the tongue for optimal absorption.
Correct Answer is A
Explanation
Rationale for A:
A small hematoma at the catheter insertion site is common after cardiac catheterization due to the puncture of blood vessels. The nurse should inform the client that this may occur but reassure them that it typically resolves on its own.
Rationale for B:
The dressing usually remains intact for 24 to 48 hours post-procedure to prevent infection and promote healing. The client should be instructed to keep the dressing clean and dry until the healthcare provider gives specific instructions.
Rationale for C: Clients are usually advised to avoid strenuous activities and exercise for several days after the procedure, not to resume regular exercise the next day.
Rationale for D: Pain medication may be necessary to manage discomfort post-procedure, and the nurse should encourage the client to take pain relief as needed.
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