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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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: This choice is incorrect as painless, raised purple nodules on the hard palate are not typically indicative of squamous cell carcinoma.

Choice B reason: This choice is incorrect because a small macule with a yellow-brown scale does not describe squamous cell carcinoma, which often presents as a firm nodule with a scaly crust.

Choice C reason: This choice is correct. Squamous cell carcinoma can present as a firm nodule with a hard, scaly crust on the skin.

Choice D reason: Yellow white patches of growth on the tongue are more indicative of conditions such as oral leukoplakia, not squamous cell carcinoma.

A. Unable to discriminate words and letters. B. Motor retardation. C. Deficits in the right visual field. D. Poor impulse control.

Correct Answer is D

Explanation

Choice A reason: This choice is incorrect. A stroke involving the right cerebral hemisphere typically affects the left side of the body and can cause problems with spatial and perceptual abilities, not necessarily with language or discrimination of words and letters, which are more commonly associated with left hemisphere strokes⁸.

Choice B reason: Motor retardation is not specific to right hemisphere strokes. While right hemisphere strokes can cause weakness on the left side of the body, the term 'motor retardation' is not commonly used to describe this symptom⁸.

Choice C reason: This choice is incorrect because deficits in the right visual field would suggest a problem with the left cerebral hemisphere, not the right. A right hemisphere stroke typically causes problems with the left visual field⁸.

Choice D reason: This is the correct choice. Individuals with right hemisphere strokes may exhibit poor impulse control, as the right hemisphere is involved in judgment and behavior regulation⁸.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is performing an integumentary assessment for a client. Which of the following findings should the nurse identify as possible squamous cell carcinoma?

Correct Answer is C

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A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

Correct Answer is D

Explanation

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