Which of the following clients diagnosed with myasthenia gravis would the nurse identify as most at risk for developing a cholinergic crisis? A client who

reports taking an extra dose each day of their anticholinesterase medication.

is experiencing a respiratory infection and is short of breath.

has a family history of autoimmune disorders.

has a past medical history of type 2 diabetes mellitus.

Answer and Explanation

The Correct Answer is A

A. "Reports taking an extra dose each day of their anticholinesterase medication."
This client is at highest risk for developing a cholinergic crisis. A cholinergic crisis occurs when there is overdose or excessive stimulation of acetylcholine receptors due to too much anticholinesterase medication. Symptoms include muscle weakness, respiratory distress, salivation, sweating, and bradycardia. Taking an extra dose of the medication can result in an overdose of acetylcholine, triggering these symptoms. Therefore, this client is at the greatest risk for a cholinergic crisis.

B. "Is experiencing a respiratory infection and is short of breath."
While respiratory infections can worsen symptoms of myasthenia gravis due to increased muscle weakness, this client is not directly at risk for a cholinergic crisis. Respiratory infections can increase the risk of myasthenic crisis, which is a different complication where muscle weakness worsens to the point of respiratory failure. A myasthenic crisis is caused by insufficient anticholinesterase medication or a disease exacerbation, not an overdose.

C. "Has a family history of autoimmune disorders."
A family history of autoimmune disorders may suggest a genetic predisposition to autoimmune diseases, but it does not increase the risk of a cholinergic crisis specifically. The risk of a cholinergic crisis is more directly related to medication management, not family history.

D. "Has a past medical history of type 2 diabetes mellitus."
Type 2 diabetes mellitus does not directly increase the risk of a cholinergic crisis. While diabetes may influence overall health and immune function, it does not have a direct impact on anticholinesterase therapy or the risk of cholinergic crisis in myasthenia gravis.

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Correct Answer is A

Explanation

A. pH 7.44; PaO2 44 mmHg; PaCO2 35 mmHg; HCO3 25 mEq/L; O2 Sat 76%: This set of arterial blood gas (ABG) values is consistent with hypoxemic respiratory failure. Hypoxemic respiratory failure is characterized by a PaO2 less than 60 mmHg, and this client has a PaO2 of 44 mmHg, which is significantly below the normal range of 80-95 mmHg. Despite the fact that the client is on a 100% non-rebreather mask (which should ideally deliver high levels of oxygen), the low PaO2 suggests that oxygenation is not being effectively improved. Additionally, the low O2 saturation of 76% further supports the diagnosis of hypoxemic respiratory failure.

B. pH 7.30; PaO2 80 mmHg; PaCO2 62 mmHg; HCO3 25 mEq/L; O2 Sat 94%: This ABG indicates respiratory acidosis (pH is low, PaCO2 is elevated), but the PaO2 of 80 mmHg is within the normal range, and the O2 saturation of 94% is also normal. Respiratory acidosis with a normal PaO2 would indicate an issue with ventilation (hypoventilation), not hypoxemic respiratory failure. The patient is retaining CO2 but is still oxygenating well, so this result does not indicate hypoxemic respiratory failure.

C. pH 7.35; PaO2 65 mmHg; PaCO2 40 mmHg; HCO3 26 mEq/L; O2 Sat 90%: This result shows a PaO2 of 65 mmHg, which is mildly low but not sufficiently low to meet the criteria for hypoxemic respiratory failure (PaO2 should be below 60 mmHg for this diagnosis). The O2 saturation of 90% is also slightly low but not critically low. This client may have mild hypoxia but is not in respiratory failure based on these values.

D. pH 7.48; PaO2 75 mmHg; PaCO2 41 mmHg; HCO3 28 mEq/L; O2 Sat 93%: In this case, the PaO2 of 75 mmHg is slightly low but still within an acceptable range, and the O2 saturation of 93% is adequate. The elevated pH and normal PaCO2 suggest the presence of respiratory alkalosis (likely caused by hyperventilation). These ABG results are not consistent with hypoxemic respiratory failure, as the oxygen levels are still within a safe range.

A. Partially compensated metabolic alkalosis B. Partially compensated metabolic acidosis C. Fully compensated respiratory acidosis D. Fully compensated respiratory alkalosis

Correct Answer is B

Explanation

A) Partially compensated metabolic alkalosis:
Metabolic alkalosis is typically characterized by an elevated pH and a high bicarbonate level (HCO3 >26 mEq/L). In this scenario, the pH is normal (7.44), and the bicarbonate level (HCO3 18 mEq/L) is low, which does not support a diagnosis of metabolic alkalosis. Furthermore, there is no evidence of compensation by respiratory mechanisms (i.e., low PaCO2). Therefore, this is not a likely diagnosis.

B) Partially compensated metabolic acidosis:
The ABG values indicate metabolic acidosis with a low bicarbonate level (HCO3 18 mEq/L) and a pH of 7.44, which is on the higher end of the normal range. A lower-than-normal bicarbonate level suggests an acidotic state, but the pH is compensating toward normal. The PaCO2 of 30 mmHg indicates a compensatory respiratory alkalosis, which would lower the PaCO2 to try to offset the acidosis. This represents a partially compensated metabolic acidosis, where the body is attempting to compensate for the acidosis but has not fully done so.

C) Fully compensated respiratory acidosis:
Respiratory acidosis is associated with elevated levels of carbon dioxide (PaCO2 >45 mmHg), which leads to a drop in pH. However, in this scenario, the PaCO2 is only 30 mmHg, which is lower than the normal range (35-45 mmHg), indicating that the problem is not respiratory acidosis. Additionally, fully compensated respiratory acidosis would show a normal pH with an elevated PaCO2 and compensatory elevation in bicarbonate levels. Thus, this option does not fit the ABG values.

D) Fully compensated respiratory alkalosis:
Respiratory alkalosis occurs when excessive CO2 is exhaled, leading to an elevated pH and a low PaCO2. Although the PaCO2 is low (30 mmHg), which could suggest respiratory alkalosis, the bicarbonate (HCO3) is low at 18 mEq/L, not high as would be expected in a fully compensated respiratory alkalosis. In a fully compensated state, the pH would be normal (around 7.4), and there would be compensatory changes in both the bicarbonate and PaCO2. Since the bicarbonate is low and the pH is not at normal levels, this diagnosis is not appropriate.

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Which of the following clients diagnosed with myasthenia gravis would the nurse identify as most at risk for developing a cholinergic crisis? A client who

Nursing Test Bank

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Explanation

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