A nurse is caring for a client with myasthenia gravis who is experiencing a myasthenic crisis with severe muscle weakness, difficulty swallowing, and respiratory distress. Which nursing action should be the highest priority?

1 Prepare for immediate endotracheal intubation and mechanical ventilation ✓ 정답
2 Administer prescribed anticholinesterase medication promptly
3 Position the client in high Fowler's position for breathing
4 Suction oral secretions to maintain airway patency now

해설

In myasthenic crisis, respiratory failure is life-threatening, so immediate intubation and mechanical ventilation are the highest priority. Other actions are supportive but secondary to airway management.

같은 주제 다음 문제A nurse is assessing a 45-year-old patient with suspected myasthenia gravis. Which assessm…이 문제가 수록된 문제집[개념+기출] 엔클렉스(NCLEX),이거 하나면 됩니다89,000원 · 무료 체험 가능

심화 해설

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.

임상 시나리오

Clinical Practice Guide The key to managing myasthenic crisis is prevention and early detection. Continuously monitor respiratory status; a decrease in vital capacity below 15-20 mL/kg or a rise in PaCO2 above 50 mmHg on arterial blood gas (ABG) analysis are signs of crisis. Additionally, if the patient complains of "shortness of breath" or "difficulty swallowing," or if speech becomes weak and the voice becomes nasal, these are danger signals. Caution: A common trap in SATA (Select All That Apply) questions is prioritizing "administration of anticholinesterase drugs." Before distinguishing whether the crisis is due to drug overdose (Cholinergic Crisis) or drug deficiency (Myasthenic Crisis), drug administration can worsen the condition. Airway and breathing must be secured first.

핵심 개념

Myasthenic Crisis — Myasthenic crisis. A life-threatening exacerbation caused by severely impaired function of acetylcholine receptors at the neuromuscular junction. It is characterized by severe muscle weakness, difficulty breathing, and difficulty swallowing, and can rapidly progress to respiratory failure.
Endotracheal Intubation — Endotracheal intubation. A procedure in which a tube is inserted into the trachea to secure the airway and provide mechanical ventilation. It is an essential emergency treatment in acute respiratory failure situations such as myasthenic crisis.
Mechanical Ventilation — Mechanical ventilation. A device that artificially assists or replaces a patient's breathing. It ensures adequate oxygenation and carbon dioxide removal in patients with respiratory muscle paralysis.
Anticholinesterase Medication — Anticholinesterase drugs (e.g., pyridostigmine, neostigmine). These are the main treatment for myasthenia gravis, improving muscle contraction by inhibiting the breakdown of acetylcholine at the neuromuscular junction.
Respiratory Distress — Dyspnea. A condition that includes a subjective feeling of difficulty breathing and objective signs (e.g., tachypnea, use of accessory respiratory muscles, anxiety). In myasthenic crisis, it appears as a direct result of respiratory muscle weakness.

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A nurse is caring for a client with myasthenia gravis who is experiencing a myasthenic crisis with severe muscle weakness, difficulty swallowing, and respiratory distress. Which nursing action should be the highest priority?

심화 해설

임상 시나리오

핵심 개념

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