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 A
Explanation
Choice A reason: Weight bearing exercises, such as walking, jogging, and dancing, are beneficial for building and maintaining bone density. These activities force the body to work against gravity, stimulating bone formation and slowing bone loss.
Choice B reason: While bone density scans are useful for diagnosing osteoporosis, they are not typically used as a preventive measure but rather as a diagnostic tool to assess bone health.
Choice C reason: Drinking coffee in moderation is not directly related to preventing osteoporosis. Excessive caffeine intake can interfere with calcium absorption, but a single cup is unlikely to have a significant impact.
Choice D reason: Increasing sodium intake is not recommended as it can lead to calcium loss through urine, which is counterproductive for bone health.
Correct Answer is D
Explanation
Choice A reason: This choice is incorrect. Partial compensation would typically involve a change in PaCO2 to counterbalance the elevated bicarbonate, which is not observed here.
Choice B reason: This choice is incorrect. Respiratory acidosis is characterized by a low pH and an elevated PaCO2, which is not consistent with the given values.
Choice C reason: This choice is incorrect. Respiratory alkalosis would present with a low PaCO2 due to hyperventilation, which is not the case here.
Choice D reason: This is the correct choice. The elevated pH and HCO3 with a normal PaCO2 indicate metabolic alkalosis without respiratory compensation. Persistent vomiting can lead to loss of stomach acid, which causes metabolic alkalosis.
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