A nurse is caring for a client who has a spinal cord injury and is developing autonomic dysreflexia. Which of the following actions should the nurse take first?

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.

Choice A reason: Garlic, ginger, and ginkgo biloba do not typically increase the effects of antidepressant medications. Instead, they may interact with other medications and alter their effectiveness.

Choice B reason: Garlic, ginger, and ginkgo biloba are known to have blood thinning properties, which means they can increase the effects of oral anticoagulants, potentially leading to an increased risk of bleeding.

Choice C reason: There is no widespread evidence to suggest that garlic, ginger, and ginkgo biloba decrease the effects of antianxiety medications. However, they may interact with other medications and should be used cautiously.

Choice D reason: While garlic has been noted for its potential to lower blood pressure, it is not commonly associated with a decrease in the effects of antihypertensive medications. In fact, it may enhance their blood pressure lowering effects.