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 B

Explanation

Choice A reason: The visibility of chest tube eyelets is not typically a concern unless there is evidence that the tube is dislodged. In normal circumstances, the eyelets may not be visible, and this does not necessarily indicate a need for intervention.

Choice B reason: The development of subcutaneous emphysema, which is the presence of air in the subcutaneous tissue, can be a sign of a serious complication such as a pneumothorax. It requires immediate assessment and possible intervention to prevent further complications.

Choice C reason: Tidal fluctuation in the water seal chamber is a normal finding when a chest tube is in place. It indicates that the system is patent and functioning correctly as it reflects the pressure changes in the pleural space during respiration.

Choice D reason: Continuous bubbling in the suction control chamber may indicate an air leak in the system, which could be normal if the system is set to continuous suction. However, if the bubbling is vigorous and the system is not set to continuous suction, it may indicate a new air leak and require intervention.

A. The test measures the hormone that attaches to a protein in your blood. B. The test measures the hormone that feeds the thyroid gland. C. The test measures the hormone that indicates the metabolic rate. D. The test measures the hormone that controls energy levels.

Correct Answer is C

Explanation

Choice A reason: The statement is incorrect because TSH does not attach to a protein in the blood; it stimulates the thyroid gland to produce thyroid hormones.

Choice B reason: This choice is partially correct. TSH does stimulate the thyroid gland, but the main purpose of the test is not to measure the 'feeding' of the gland but to assess its function and how well it's producing thyroid hormones.

Choice C reason: This is the correct statement. TSH levels are measured to determine the thyroid gland's activity, which directly influences the metabolic rate. The normal range for TSH levels in adults is typically 0.4 to 4.0 milliunits per liter (mU/L). However, these values can vary slightly based on the laboratory and the age of the individual.

Choice D reason: While TSH does influence energy levels by regulating thyroid hormone production, this choice does not directly explain the purpose of measuring TSH levels.

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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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