A nurse suspects a client with myasthenia gravis is experiencing a myasthenic crisis. Which of the following interventions should the nurse take?
Prepare to administer a vasopressor.
Administer an anticholinesterase medication.
Prepare the client for intubation.
Instruct the client to perform pursed lip breathing.
The Correct Answer is C
The correct answer is: c. Prepare the client for intubation.
Choice A: Prepare to administer a vasopressor
Reason: Vasopressors are typically used to manage hypotension (low blood pressure) and are not a standard treatment for myasthenic crisis. Myasthenic crisis primarily involves respiratory muscle weakness, which can lead to respiratory failure, rather than issues with blood pressure.
Choice B: Administer an anticholinesterase medication
Reason: While anticholinesterase medications like pyridostigmine are used to manage myasthenia gravis, they are generally not recommended during a myasthenic crisis. During a crisis, the focus is on stabilizing the patient, often requiring more immediate interventions such as intubation and mechanical ventilation.
Choice C: Prepare the client for intubation
Reason: Intubation is a critical intervention in a myasthenic crisis due to the risk of respiratory failure. The crisis is characterized by severe muscle weakness, including the muscles that control breathing. Intubation ensures that the airway is protected and that the patient can receive adequate ventilation.
Choice D: Instruct the client to perform pursed lip breathing
Reason: Pursed lip breathing is a technique used to improve breathing efficiency in conditions like chronic obstructive pulmonary disease (COPD). However, it is not appropriate for managing a myasthenic crisis, where the primary issue is severe muscle weakness leading to respiratory failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Respiratory Alkalosis Partially Compensated is characterized by an elevated pH over 7.45 and a PaCO2 under 35 mmHg, with a compensatory acidic HCO3 under 22 mEq/L. This does not match the patient's ABG results.
Choice B reason: Respiratory Acidosis Uncompensated is indicated by an acidic pH under 7.35 and an elevated PaCO2 over 45 mmHg, with HCO3 in the normal range of 2226 mEq/L. The patient's ABG results show a low pH and high PaCO2, which aligns with this condition.
Choice C reason: Metabolic Alkalosis Partially Compensated would show a basic pH over 7.45 and a basic HCO3 over 26 mEq/L, with a compensatory acidic PaCO2 over 45 mmHg[^10^]. The patient's ABG values do not support this diagnosis.
Choice D reason: Metabolic Acidosis Uncompensated would present with an acidic pH under 7.35 and an acidic HCO3 under 22 mEq/L, with PaCO2 in the normal range of 3545 mmHg⁸. The patient's normal HCO3 level does not indicate metabolic acidosis.
Correct Answer is B
Explanation
Choice A reason: This choice is incorrect because an oral cholangiogram does not involve putting a camera down the throat. That procedure is more akin to an endoscopy.
Choice B reason: This statement is correct. An oral cholangiogram involves taking an Xray examination of the gallbladder after the patient has taken an iodine based contrast agent orally. The procedure is used to diagnose problems related to the gallbladder, such as gallstones or issues with bile flow.
Choice C reason: This choice is incorrect because an oral cholangiogram does not involve putting medication into the gallbladder to dissolve stones. That description is more consistent with nonsurgical treatments for gallstones, such as oral bile acid pills.
Choice D reason: This choice is incorrect as it describes a different procedure known as extracorporeal shock wave lithotripsy (ESWL), which uses shock waves to break up gallstones.
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