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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Renal function is not typically reestablished during the oliguric phase of acute kidney injury; this phase is characterized by a significant reduction in urine output due to renal tubule damage.
Choice B reason: BUN and creatinine levels usually increase during the oliguric phase because the kidneys' ability to filter and excrete these waste products is compromised.
Choice C reason: The oliguric phase is defined by a urine output of less than 400 mL per 24 hours, which is a result of decreased kidney function and damage to the renal tubules.
Choice D reason: The GFR does not recover during the oliguric phase; instead, it is typically low due to reduced kidney function. Recovery of GFR occurs later in the recovery phase of acute kidney injury.
Correct Answer is A
Explanation
Choice A reason: play a crucial role in transplant rejection. They can recognize and attack foreign tissues, including transplanted organs, leading to rejection. This immune response is a significant concern in transplant medicine, and managing T cell activity is essential for the success of organ transplants.
Choice B reason: While anaphylaxis is an acute allergic reaction, it is more commonly associated with the release of histamines and other mediators from mast cells and basophils. can contribute to the severity of the reaction, but they are not the primary cells involved in anaphylaxis.
Choice C reason: Bacterial phagocytosis is primarily the function of phagocytes like neutrophils and macrophages. do not directly engage in phagocytosis but can activate other immune cells that do.
Choice D reason: Hay fever, or allergic rhinitis, involves an immune response to airborne allergens, with contributing to the development of symptoms by helping to produce IgE antibodies. However, the immediate symptoms of hay fever are more directly related to mast cell activation rather than activity.
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