A nurse is caring for a client with myasthenia gravis who is… | 마이메르시 MyMerci
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문제

A nurse is caring for a client with myasthenia gravis who is experiencing a myasthenic crisis. Which nursing action should be the highest priority?

해설
In myasthenic crisis, airway assessment and maintenance are the priority due to risk of respiratory failure. Other interventions like medication or positioning are secondary until airway is secured.
같은 주제 다음 문제A nurse is assessing a 45-year-old patient with suspected myasthenia gravis. Which assessm…

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: Myasthenic Crisis
Rapid Response & ABC Assessment

Upon recognizing signs of myasthenic crisis (dyspnea, tachypnea, weak cough, inability to clear secretions), immediately assess the airway, breathing, and circulation. The highest priority is evaluating respiratory rate, depth, oxygen saturation, and the patient's ability to protect their airway. Maintain a patent airway using positioning, suctioning, or adjuncts as needed while continuously monitoring for impending respiratory arrest.

Escalation & Ventilatory Support

Notify the provider and prepare for emergency airway management. Have endotracheal intubation equipment and a bag-valve-mask device at the bedside. Non-invasive positive pressure ventilation (BiPAP) may be used temporarily, but progressive hypercapnia or hypoxia necessitates definitive airway control and mechanical ventilation. Serial monitoring of negative inspiratory force (NIF) and vital capacity (VC) guides the timing of intubation.

Pharmacologic & Definitive Therapies

Administer prescribed anticholinesterase inhibitors (e.g., pyridostigmine) as ordered, but never delay airway intervention for medication administration. Plasmapheresis or intravenous immunoglobulin (IVIG) are first-line immunomodulatory treatments to rapidly reverse the crisis. Corticosteroids may be initiated with caution due to potential transient worsening of weakness.

Ongoing Monitoring & Supportive Care

Monitor for complications such as aspiration pneumonia, atelectasis, and deep vein thrombosis. Implement strict aspiration precautions, including frequent oral suctioning and keeping the head of bed elevated. Provide meticulous eye care if the patient has ptosis or impaired lid closure. Once stabilized, collaborate with respiratory therapy and physical therapy for gradual weaning and rehabilitation.

핵심 개념

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