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

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=541189  
> language: ko  
> subject: Adult Health

## 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?

## 보기

1. Administer prescribed anticholinesterase medication immediately
2. Position the client in high Fowler's position to improve breathing
3. Prepare for emergency intubation and mechanical ventilation **✔ 정답**
4. Provide emotional support and reassurance to reduce anxiety

**정답: 3**

## 해설

In myasthenic crisis, respiratory failure is the immediate threat, so preparing for emergency intubation and mechanical ventilation is the highest priority. Other actions are secondary as they do not address the imminent airway compromise.

## 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 Priority: Myasthenic Crisis

In a myasthenic crisis, the diaphragm and intercostal muscles fail due to insufficient acetylcholine receptor activation. The immediate threat is hypercapnic respiratory failure and airway collapse, not merely dyspnea. The nurse's primary action is to prepare for definitive airway management—emergency intubation and mechanical ventilation—to ensure oxygenation and ventilation while pharmacologic interventions take effect. This follows the ABC (Airway, Breathing, Circulation) priority framework, where a compromised airway and ineffective breathing override all other interventions.

**Key Actions:**

- **Assess Rapidly:** Monitor vital capacity, negative inspiratory force, and single breath count. A vital capacity below 15-20 mL/kg or inability to count past 10-15 in one breath indicates impending respiratory arrest.

- **Secure Airway:** Have intubation equipment, suction, and a bag-valve-mask device at the bedside. Notify the rapid response team and respiratory therapy immediately.

- **Support Breathing:** Once intubated, mechanical ventilation rests the respiratory muscles while plasmapheresis or IV immunoglobulin and high-dose corticosteroids address the underlying crisis.

- **Medication Safety:** Hold anticholinesterase medications immediately before and after intubation to reduce secretions, then resume as ordered once the airway is secure.

## 핵심 개념

- **Myasthenic Crisis** — Myasthenic crisis. An acute exacerbation caused by severe impairment of acetylcholine receptor function at the neuromuscular junction, leading to profound muscle weakness, particularly paralysis of respiratory and swallowing muscles, which can be life-threatening.
- **Cholinergic Crisis** — Cholinergic crisis. It occurs due to overdose of anticholinesterase drugs (e.g., pyridostigmine), and presents with muscle weakness, sweating, excessive salivation, bradycardia, etc., due to excessive acetylcholine accumulation. The symptoms resemble those of myasthenic crisis, making differentiation important.
- **Anticholinesterase Medication** — Anticholinesterase drugs (e.g., Pyridostigmine). These are the main treatment for myasthenia gravis, improving muscle contraction by inhibiting the breakdown of acetylcholine at the neuromuscular junction.
- **Respiratory Distress** — Shortness of breath. A condition where breathing is difficult, with symptoms such as rapid breathing, use of accessory respiratory muscles, anxiety, and cyanosis. It is the most dangerous sign in a myasthenic crisis.
- **Mechanical Ventilation** — Mechanical ventilation. It is a treatment that uses a device to artificially assist or replace the patient's breathing. It is essential after securing the airway in cases of respiratory failure.

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