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 C

Explanation

Choice A reason: Dullness on percussion typically indicates increased lung density, such as in conditions where lung tissue is consolidated or fluid-filled. This sound is heard in cases of:Pneumonia (due to alveolar consolidation)Pleural effusion (fluid in the pleural space)Lung tumors (solid masses in lung tissue) Since chronic bronchitis is primarily an airway disease characterized by inflammation and mucus production rather than lung consolidation or fluid accumulation, dullness is not an expected finding..

Choice B reason: Tympany is usually heard over air-filled structures and is not a percussion sound typically associated with chronic bronchitis.

Choice C reason:

Resonance is the normal percussion sound heard over healthy lung fields, indicating air-filled alveoli. Since chronic bronchitis does not cause significant air trapping or lung consolidation, percussion remains resonant rather than hyperresonant (as in emphysema) or dull (as in pneumonia). Thus, resonance is the expected finding in chronic bronchitis because the lung parenchyma remains relatively unaffected despite the chronic airway inflammation.

Choice D reason: Flatness is heard over very dense tissue, such as muscle or bone, and is not characteristic of chronic bronchitis.

A. Chest tube eyelets not visible B. Development of subcutaneous emphysema C. Presence of tidal fluctuation in the water seal chamber D. Continuous bubbling in the suction control chamber

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.

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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?

Nursing Test Bank

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