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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason: Diabetes mellitus is not directly associated with acute pancreatitis. However, longstanding diabetes can lead to chronic pancreatitis due to the damage it causes to the pancreas over time.

Choice B reason: Hyperlipidemia, specifically high levels of triglycerides in the blood, can be a risk factor for acute pancreatitis. Elevated triglyceride levels above 1000 mg/dL can precipitate an episode of acute pancreatitis.

Choice C reason: Gallstones are a common cause of acute pancreatitis. They can block the bile duct, leading to pancreatitis. It's estimated that gallstone disease is responsible for 3040% of acute pancreatitis cases.

Choice D reason: A criminal record is not a medical condition and has no relevance to the development of acute pancreatitis.

A. Offer the client the bedpan every 2 hours. B. Cleanse the perineum from front to back. C. Encourage fluid intake at and between meals. D. Obtain a prescription for an indwelling urinary catheter.

Correct Answer is C

Explanation

Choice A reason: Offering the bedpan every 2 hours is not specifically related to preventing urinary tract infections (UTIs) and may not be necessary unless the client has other needs that require frequent toileting.

Choice B reason: Cleansing the perineum from front to back is a standard practice to prevent the spread of bacteria from the anal area to the urethra, which can reduce the risk of UTIs.

Choice C reason: Encouraging fluid intake is crucial for clients with a spinal cord injury because it helps to flush out the urinary tract, preventing the buildup of bacteria that can cause UTIs.

Choice D reason: An indwelling urinary catheter may be necessary for a client with a T4 spinal cord injury who cannot effectively empty the bladder, but it should be used with caution as it can also increase the risk of UTIs. The decision to use an indwelling catheter should be based on a thorough assessment and consideration of all other options.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is interviewing a client who has acute pancreatitis. Which of the following factors should the nurse anticipate finding in the client's history?

Correct Answer is C

Explanation

A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care?

Correct Answer is C

Explanation

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