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NurseDive Free Nursing Practice Question
A nurse suspects a client who has myasthenia gravis is experiencing a myasthenic crisis. Which of the following interventions should the nurse take?
A. Administer an anticholinesterase medication.
Administer an anticholinesterase medication. This statement is incorrect because anticholinesterase medications, such as pyridostigmine or neostigmine, are used to treat the symptoms of myasthenia gravis by inhibiting the enzyme that breaks down acetylcholine, which is the neurotransmiter that stimulates muscle contraction. However, these medications can also cause a cholinergic crisis, which is another complication of myasthenia gravis that occurs when there is too much acetylcholine in the neuromuscular junction, causing muscle weakness and paralysis. The nurse should not administer an anticholinesterase medication without confirming the cause of the crisis, as this can worsen the condition and mask the signs of respiratory distress.
B. Instruct the client to perform the pursed lip breathing.
Instruct the client to perform the pursed lip breathing. This statement is incorrect because pursed lip breathing is a technique that helps to slow down and control breathing, reduce air trapping, and improve gas exchange. It is used to manage chronic obstructive pulmonary disease (COPD), asthma, or anxiety. It is not helpful for a client who has a myasthenic crisis, as their respiratory muscles are too weak to maintain adequate ventilation, regardless of their breathing patern.
C. Prepare to administer a vasoconstrictor.
Prepare to administer a vasoconstrictor. This statement is incorrect because vasoconstrictors are medications that narrow the blood vessels and increase blood pressure. They are used to treat hypotension, shock, or hemorrhage. They are not helpful for a client who has a myasthenic crisis, as their problem is not related to blood pressure or blood flow, but to respiratory muscle weakness and inadequate ventilation.
D. Prepare the client for mechanical ventilation.
This is correct Myasthenia gravis is a chronic autoimmune disorder that affects the neuromuscular junction, causing weakness and fatigue of the voluntary muscles. A myasthenic crisis is a life-threatening complication of myasthenia gravis that occurs when the respiratory muscles become too weak to maintain adequate ventilation. Symptoms of a myasthenic crisis include severe dyspnea, cyanosis, tachycardia, tachypnea, and hypoxia. The nurse should prepare the client for mechanical ventilation.
This question is an excerpt from Nurse Dive's nursing test bank - College Proctored Exam 2 perfusion euro pm. Take the full exam now
Full Explanation
Choice A reason:
Administering an anticholinesterase medication is not the primary intervention during a myasthenic crisis. While these medications can improve muscle strength in myasthenia gravis, they are not sufficient in the event of a crisis.
Choice B reason:
Pursed lip breathing is a technique used to manage dyspnea but is not adequate for the acute management of a myasthenic crisis, which can involve respiratory muscle paralysis.
Choice C reason:
Vasoconstrictors are not used in the treatment of myasthenic crisis. This condition is not related to vascular issues but to neuromuscular transmission failure leading to respiratory failure.
Choice D reason:
Mechanical ventilation is the correct intervention as it provides the necessary respiratory support when the patient's respiratory muscles are too weak to maintain adequate ventilation.
Similar Questions
While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care?
A. Alteration in body image
Alteration in body image. This is a nursing diagnosis that indicates a negative perception or dissatisfaction with one's physical appearance or function. It may be applicable for a client who has varicose veins with ulcerations and lower extremity edema, as these may affect their self-esteem and social interactions. However, it is not the priority nursing diagnosis for this client, as it does not pose an immediate threat to their health or safety.
B. Alteration in activity tolerance
Alteration in activity tolerance. This is a nursing diagnosis that indicates a decrease in the ability to perform physical activities without experiencing fatigue, dyspnea, or other symptoms. It may be applicable for a client who has varicose veins with ulcerations and lower extremity edema, as these may limit their mobility and endurance. However, it is not the priority nursing diagnosis for this client, as it does not pose an immediate threat to their health or safety.
C. Impaired tissue perfusion
Impaired tissue perfusion is a nursing diagnosis that indicates a decrease in oxygen and nutrient delivery to the tissues, resulting in cellular dysfunction and potential tissue damage or necrosis. It is the priority nursing diagnosis for a client who has varicose veins with ulcerations and lower extremity edema, as these are signs of chronic venous insufficiency, which is a condition in which the veins in the legs fail to return blood to the heart effectively, causing blood to pool and stagnate in the lower extremities. This leads to increased venous pressure, inflammation, and impaired wound healing, which can cause skin breakdown, infection, and tissue necrosis. The nurse should monitor the client's vital signs, peripheral pulses, capillary refill, skin color, temperature, and sensation, and implement interventions to improve venous return and prevent further complications, such as elevating the legs, applying compression stockings, encouraging ambulation, administering medications, and providing wound care.
D. Impaired skin integrity
Impaired skin integrity. This is a nursing diagnosis that indicates a disruption or damage to the epidermis or dermis layers of the skin. It is applicable for a client who has varicose veins with ulcerations and lower extremity edema, as these can cause skin breakdown and infection. However, it is not the priority nursing diagnosis for this client, as it is a consequence of impaired tissue perfusion, which is the underlying problem that needs to be addressed first.
Full Explanation
Impaired tissue perfusion is a nursing diagnosis that indicates a decrease in oxygen and nutrient delivery to the tissues, resulting in cellular dysfunction and potential tissue damage or necrosis. It is the priority nursing diagnosis for a client who has varicose veins with ulcerations and lower extremity edema, as these are signs of chronic venous insufficiency, which is a condition in which the veins in the legs fail to return blood to the heart effectively, causing blood to pool and stagnate in the lower extremities. This leads to increased venous pressure, inflammation, and impaired wound healing, which can cause skin breakdown, infection, and tissue necrosis. The nurse should monitor the client's vital signs, peripheral pulses, capillary refill, skin color, temperature, and sensation, and implement interventions to improve venous return and prevent further complications, such as elevating the legs, applying compression stockings, encouraging ambulation, administering medications, and providing wound care.
Alteration in body image. This is a nursing diagnosis that indicates a negative perception or dissatisfaction with one's physical appearance or function. It may be applicable for a client who has varicose veins with ulcerations and lower extremity edema, as these may affect their self-esteem and social interactions. However, it is not the priority nursing diagnosis for this client, as it does not pose an immediate threat to their health or safety.
Alteration in activity tolerance. This is a nursing diagnosis that indicates a decrease in the ability to perform physical activities without experiencing fatigue, dyspnea, or other symptoms. It may be applicable for a client who has varicose veins with ulcerations and lower extremity edema, as these may limit their mobility and endurance. However, it is not the priority nursing diagnosis for this client, as it does not pose an immediate threat to their health or safety.
Impaired skin integrity. This is a nursing diagnosis that indicates a disruption or damage to the epidermis or dermis layers of the skin. It is applicable for a client who has varicose veins with ulcerations and lower extremity edema, as these can cause skin breakdown and infection. However, it is not the priority nursing diagnosis for this client, as it is a consequence of impaired tissue perfusion, which is the underlying problem that needs to be addressed first.
A nurse is caring for a client who is postoperative following an appendectomy and is prescribed 1 L lactated Ringer's at 150 mL/hr by continuous IV infusion for 12 hr. The drop factor of the manual IV tubing is 20 gt/mL. The nurse should set the manual IV infusion to deliver how many gt/min?
Full Explanation
To calculate the gt/min, the nurse should use the following formula:
gt/min = (mL/hr x drop factor) / 60
Plugging in the given values, we get:
gt/min = (150 mL/hr x 20 gt/mL) / 60
gt/min = 3000 gt/hr / 60 gt/min = 50 gt/min
Therefore, the nurse should set the manual IV infusion to deliver 50 gt/min.
A nurse is caring for a client who has sepsis and a prescription for vancomycin 1 g in 250 mL dextrose 5% (D5W) over 2 hr by IV intermitent bolus. The nurse should set the IV pump to deliver how many mL/hr?
(Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Full Explanation
To calculate the infusion rate, the nurse should use the following formula:
Infusion rate (mL/hr) = Volume (mL) / Time (hr)
Plugging in the given values, the nurse should get:
Infusion rate (mL/hr) = 250 mL / 2 hr
Infusion rate (mL/hr) = 125 mL/hr
The nurse should round the answer to the nearest whole number and use a leading zero if it applies. Therefore, the nurse should set the IV pump to deliver 125 mL/hr.