The critical care nurse is admitting a client in myasthenic crisis to the ICU. The nurse should prioritize what nursing action in the immediate care of this client?

Providing ventilatory assistance

Facilitating ABG analysis

Suctioning secretions

Administering tube feedings

Answer and Explanation

The Correct Answer is A

A. Providing ventilatory assistance: Myasthenic crisis involves severe muscle weakness, including the respiratory muscles, posing an immediate threat to airway and breathing. Ventilatory support is the highest priority to maintain oxygenation and prevent respiratory failure during this acute phase.

B. Facilitating ABG analysis: Arterial blood gas analysis is useful in evaluating respiratory status but does not take precedence over actually ensuring adequate ventilation. ABGs are diagnostic tools and should follow stabilization of the airway and breathing.

C. Suctioning secretions: Suctioning may be necessary, especially if the client has difficulty clearing secretions. However, suctioning is secondary to establishing ventilatory support, which addresses the root issue of respiratory insufficiency.

D. Administering tube feedings: Tube feeding is important for nutrition but is not an immediate concern in a myasthenic crisis. During respiratory compromise, maintaining a patent airway and supporting ventilation must come first before addressing nutritional needs.

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Correct Answer is C

Explanation

A. Generalized pain: Pain may be present but is non-specific and not typically used to gauge neurological deterioration. It does not provide reliable early warning of increased intracranial pressure or worsening stroke symptoms.

B. Tonic-clonic seizures: Seizures may occur as a complication of hemorrhagic stroke, but they are generally a later or more severe sign of neurological compromise. Earlier signs usually include subtle mental status changes.

C. Alteration in level of consciousness (LOC): A change in LOC is often the earliest and most sensitive indicator of increased intracranial pressure or neurological deterioration. Even minor confusion or drowsiness can suggest worsening cerebral function.

D. Shortness of breath: Respiratory changes can indicate brainstem involvement but are more often seen in later stages of neurological decline. Early deterioration from a hemorrhagic stroke typically presents first with cognitive or consciousness changes.

A. Place a wedge pillow between the legs. B. Elevate the head of the bed to a Fowler's position. C. Position the legs in alignment with the spine. D. Place a footboard on the bed.

Correct Answer is A

Explanation

A. Place a wedge pillow between the legs: A wedge pillow maintains proper hip abduction and prevents the legs from crossing the midline, reducing the risk of hip dislocation after surgery. It stabilizes the joint and ensures that the hip remains in a neutral position during recovery.

B. Elevate the head of the bed to a Fowler's position: Elevating the head of the bed too far can cause hip flexion greater than 90 degrees, increasing the risk of dislocation. While slight elevation may aid comfort and breathing, high Fowler’s should be avoided post-hip arthroplasty.

C. Position the legs in alignment with the spine: While keeping the legs straight may seem neutral, this position does not prevent the legs from adducting or rotating inward, which can contribute to dislocation risk. Abduction is more protective in this context.

D. Place a footboard on the bed: A footboard can help prevent foot drop but does not play a role in preventing hip dislocation. It provides no stabilization to the hip joint and does not ensure safe alignment of the lower extremities.

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The critical care nurse is admitting a client in myasthenic crisis to the ICU. The nurse should prioritize what nursing action in the immediate care of this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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