2Position the client in high Fowler's position to improve breathing
3Prepare for immediate endotracheal intubation and mechanical ventilation✓ 정답
4Provide emotional support and reassurance to reduce anxiety
해설
In myasthenic crisis, immediate preparation for intubation and ventilation is priority to prevent respiratory failure. Other interventions are secondary until airway is managed.
Clinical Judgment
This question evaluates your ability in prioritization and emergency management. The greatest threat in a myasthenic crisis is acute respiratory failure due to respiratory muscle weakness. Therefore, the nurse's first and most important task is to secure the Airway and Breathing. Option 1, 'Assess respiratory status and prepare for mechanical ventilation,' is the top priority because it involves a proactive and immediate response to potential or ongoing respiratory failure. Other interventions are important considerations after the respiratory status is stabilized.
Memory Tip: Remember the ABCs! Always prioritize in the order of Airway, Breathing, and Circulation. A myasthenic crisis directly threatens Breathing.
KR vs US: The fundamental principle of prioritizing respiratory preservation is the same in both Korea and the US. However, in the US NCLEX, the phrase "Prepare for" is interpreted as an active nursing action that includes specific tasks (checking equipment, alerting the team, establishing a plan). While a nurse cannot independently initiate mechanical ventilation immediately, all preparatory actions for its potential need are the highest priority.
Clinical Priority in Myasthenic Crisis
Myasthenic crisis is a neurologic emergency defined by respiratory muscle failure. The immediate threat is loss of airway protection and hypoventilation, which can rapidly progress to complete airway obstruction and cardiopulmonary arrest. Nursing management must follow the ABC (Airway, Breathing, Circulation) framework, making proactive airway stabilization the absolute priority over pharmacological or positional interventions.
Nursing Actions for Impending Respiratory Failure
Recognize early signs of crisis: tachypnea, shallow respirations, paradoxical breathing, accessory muscle use, and inability to handle secretions.
Immediately call the rapid response team and prepare emergency airway equipment (endotracheal tube, bag-valve-mask, suction, ventilator).
Position the client upright only if it does not delay definitive airway management; do not rely on positioning alone to reverse ventilatory failure.
Administer prescribed anticholinesterase medications only after the airway is secured or as a temporizing measure while preparing for intubation, as these agents may not reverse crisis rapidly enough.
Continuously monitor oxygen saturation, end-tidal CO2, and respiratory pattern; have emergency medications (e.g., atropine for bradycardia) readily available during intubation.
Post-Intubation and Ongoing Care
Once mechanical ventilation is initiated, collaborate with respiratory therapy to optimize ventilator settings. Continue to assess for complications such as ventilator-associated pneumonia, and provide frequent oral care. Address anxiety and communication needs by establishing alternative communication methods (e.g., writing boards). Coordinate with the healthcare team to identify and treat the underlying trigger of the crisis (e.g., infection, medication changes).
Myasthenic Crisis — A life-threatening complication of myasthenia gravis characterized by severe weakness of respiratory muscles leading to acute respiratory failure and the need for ventilatory support.
ABC Priority — A triage framework prioritizing Airway, Breathing, and Circulation; in myasthenic crisis, securing the airway and supporting ventilation is the highest priority.