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 B
Explanation
The P wave is the first wave on the ECG strip and represents the electrical activity of the atria. It reflects the depolarization of the atrial myocardium, which is the process of changing the electrical charge of the cardiac cells from negative to positive, triggering a contraction. The P wave precedes the QRS complex, which represents ventricular depolarization, and the T wave, which represents ventricular repolarization.
The other options are not correct because:
a. Slow repolarization of ventricular Purkinje fibers. This statement is incorrect because it describes the U wave, which is a small and sometimes invisible wave that follows the T wave on the ECG strip. It reflects the repolarization of the ventricular Purkinje fibers, which are specialized cardiac cells that conduct electrical impulses to the ventricles. The U wave is more prominent in conditions that cause hypokalemia, such as diuretic use or vomiting.
c. Early ventricular repolarization. This statement is incorrect because it describes the ST segment, which is the flat line between the QRS complex and the T wave on the ECG strip. It reflects the early phase of ventricular repolarization, which is the process of restoring the electrical charge of the cardiac cells to negative after a contraction. The ST segment can be elevated or depressed in conditions that cause myocardial ischemia or injury, such as angina or myocardial infarction.
d. Ventricular depolarization. This statement is incorrect because it describes the QRS complex, which is the largest and most visible wave on the ECG strip. It reflects the depolarization of the ventricular myocardium, which triggers a ventricular contraction. The QRS complex follows the P wave and precedes the T wave on the ECG strip.
Correct Answer is C
Explanation
Obtaining a pair of slipper socks for the client is a simple and safe way to provide warmth and insulation to the feet, which can improve blood flow and comfort.
Placing a moist heating pad under the client's feet is not recommended, as it can cause burns, vasodilation, or increased fluid loss, which can worsen the condition.
Increasing the client's oral fluid intake is not relevant, as it does not affect the temperature or circulation of the feet.
Rubbing the client's feet briskly for several minutes is not advisable, as it can cause trauma, inflammation, or ulceration to the fragile skin and tissues of the feet.
Obtaining a pair of slipper socks for the client is a simple and safe way to provide warmth and insulation to the feet, which can improve blood flow and comfort.
Placing a moist heating pad under the client's feet is not recommended, as it can cause burns, vasodilation, or increased fluid loss, which can worsen the condition.
Increasing the client's oral fluid intake is not relevant, as it does not affect the temperature or circulation of the feet.
Rubbing the client's feet briskly for several minutes is not advisable, as it can cause trauma, inflammation, or ulceration to the fragile skin and tissues of the feet.
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