# A nurse is caring for a client with myasthenia gravis who is experiencing a myasthenic crisis. Which nursing intervention should be the priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541185 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a client with myasthenia gravis who is experiencing a myasthenic crisis. Which nursing intervention should be the priority? The client is experiencing severe muscle weakness, difficulty swallowing, and respiratory distress. ## 보기 1. Administer prescribed anticholinesterase medication immediately 2. Prepare for endotracheal intubation and mechanical ventilation **✔ 정답** 3. Position the client in high Fowler's position to improve breathing 4. Provide emotional support and reassurance to reduce anxiety **정답: 2** ## 해설 In myasthenic crisis, respiratory failure is the most life-threatening complication, so preparing for endotracheal intubation and mechanical ventilation is the priority. Other interventions like medication or positioning are supportive but do not address the immediate airway threat. ## 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 **A**BCs! Always prioritize in the order of **A**irway, **B**reathing, and **C**irculation. A myasthenic crisis directly threatens **B**reathing. 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 Scenario A client with known myasthenia gravis presents with severe generalized weakness, dysphagia, and increasing respiratory distress with shallow, rapid breathing. Breath sounds are diminished bilaterally, and the client is unable to clear secretions. Vital signs show tachycardia and declining oxygen saturation despite supplemental oxygen. Immediate Nursing Actions - Activate rapid response or code team immediately due to impending respiratory arrest. - Assess airway patency and breathing effort continuously; monitor for paradoxical breathing or use of accessory muscles. - Prepare emergency airway equipment: endotracheal tube, laryngoscope, suction, bag-valve-mask device, and mechanical ventilator. - Assist with rapid sequence intubation as ordered; have emergency medications (e.g., sedatives, paralytics) available per protocol. - Once airway is secured, verify tube placement via end-tidal CO2 detection and chest auscultation, then initiate mechanical ventilation. Ongoing Management and Monitoring - Continue anticholinesterase therapy as prescribed once airway is stable; note that medication adjustments may be needed during crisis. - Monitor for signs of cholinergic crisis (excessive salivation, bradycardia, fasciculations) if medications are administered. - Position client with head of bed elevated 30-45 degrees if not contraindicated to reduce aspiration risk and optimize ventilation. - Perform frequent respiratory assessments including breath sounds, SpO2, ABG analysis, and ventilator settings. - Provide suctioning as needed to maintain airway patency; use sterile technique and hyperoxygenate before suctioning. - Address communication needs and anxiety once the client is stabilized; explain all procedures clearly. Clinical Pearls Myasthenic crisis is defined by respiratory failure requiring ventilatory support. The priority is always airway protection and ventilation, not medication administration. Bulbar weakness increases aspiration risk dramatically, so even positioning changes must be done cautiously. Plasmapheresis or IV immunoglobulin may be initiated after stabilization to treat the underlying crisis. ## 핵심 개념 - **Myasthenic Crisis** — A life-threatening complication of myasthenia gravis characterized by severe respiratory and bulbar muscle weakness leading to respiratory failure. - **Anticholinesterase Medication** — Drugs such as pyridostigmine that inhibit acetylcholinesterase, increasing acetylcholine availability at the neuromuscular junction to improve muscle strength. - **Bulbar Muscles** — Muscles innervated by cranial nerves in the brainstem controlling speech, swallowing, and airway protection. - **Endotracheal Intubation** — Placement of a flexible tube into the trachea to maintain a patent airway and facilitate mechanical ventilation. ## 같은 주제 문제 - [A nurse is assessing a 45-year-old patient with suspected myasthenia gravis. 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