# Situation: A 34-year-old woman with generalized myasthenia gravis (MG) is admitted to the medical ward with fever and a productive cough. She weighs 60 kg. She takes pyridostigmine 60 mg by mouth every 6 hours and prednisone 10 mg once daily. She has no drug allergies. The nurse writes her plan of care for the next 24 hours. Which interventions should be included? 1. Serve meals about 45 minutes after each pyridostigmine dose 2. Schedule her bath and walk for the late evening 3. Keep suction and a bag-valve mask at the bedside 4. Give a double dose if a pyridostigmine dose is missed

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630327  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 34-year-old woman with generalized myasthenia gravis (MG) is admitted to the medical ward with fever and a productive cough. She weighs 60 kg. She takes pyridostigmine 60 mg by mouth every 6 hours and prednisone 10 mg once daily. She has no drug allergies.

The nurse writes her plan of care for the next 24 hours. Which interventions should be included?
1. Serve meals about 45 minutes after each pyridostigmine dose
2. Schedule her bath and walk for the late evening
3. Keep suction and a bag-valve mask at the bedside
4. Give a double dose if a pyridostigmine dose is missed

## 보기

1. 1 and 2
2. 1 and 3 **✔ 정답**
3. 3 and 4
4. 1, 2 and 3

**정답: 2**

## 해설

Pyridostigmine is taken 30 to 60 minutes before meals so that strength is greatest while she chews and swallows. Weakness in myasthenia gravis worsens with activity and toward the end of the day, so demanding activities are not scheduled for the late evening. Suction and a bag-valve mask are kept ready because bulbar and respiratory weakness can progress quickly, and doses are never doubled.

## 심화 해설

Core issue

This patient has generalized myasthenia gravis (MG), an autoimmune disorder in which antibodies attack acetylcholine receptors at the neuromuscular junction. The result is fluctuating, fatigable weakness of voluntary muscles, including those used for chewing, swallowing, and breathing. She now has a respiratory infection, which increases her risk of rapid deterioration because fever and infection can worsen MG weakness and trigger a myasthenic crisis.

Intervention 1: Meals 45 minutes after pyridostigmine

Pyridostigmine is an acetylcholinesterase inhibitor. It prevents the breakdown of acetylcholine at the neuromuscular junction, so more acetylcholine is available to bind to the remaining receptors. Peak effect occurs roughly 30 to 60 minutes after an oral dose. Serving meals about 45 minutes after the dose means the patient eats when chewing and swallowing strength is at its best. This reduces the risk of aspiration and improves oral intake. Timing meals to the peak action of pyridostigmine is a standard safety measure in MG nursing care. This intervention is correct.

Intervention 2: Bath and walk in the late evening

MG weakness is fatigable: it worsens with repeated or sustained activity and typically becomes more pronounced as the day progresses. A bath and a walk are both demanding activities that require sustained muscle effort. Scheduling them late in the evening places them at the time when the patient is most likely to be weak. Demanding activities should be planned for the morning or shortly after a pyridostigmine dose, not late in the evening. This intervention is incorrect.

Intervention 3: Suction and bag-valve mask at the bedside

Generalized MG can involve bulbar muscles, which control swallowing, gagging, and airway protection, as well as the diaphragm and intercostal muscles. A respiratory infection adds secretions and increased metabolic demand. If weakness progresses, the patient may be unable to clear secretions or maintain adequate ventilation. Keeping suction and a bag-valve mask immediately available is a critical safety precaution because respiratory and bulbar failure can develop quickly. This intervention is correct.

Intervention 4: Double the dose if a pyridostigmine dose is missed

Pyridostigmine has a narrow therapeutic window. Giving a double dose can push the patient from too little acetylcholine into cholinergic crisis, which produces excessive muscarinic and nicotinic effects, including increased secretions, bronchospasm, bradycardia, and worsening muscle weakness. The clinical picture can resemble myasthenic crisis, making differentiation difficult. Watch out! A missed dose is never corrected by doubling the next dose. The prescriber must be notified, and the dose is simply resumed on schedule or adjusted per order. This intervention is incorrect.

Why the combination matters

The correct answer is 2, which includes interventions 1 and 3. Both address the two highest-priority risks in this patient: aspiration due to weak swallowing muscles and respiratory failure due to weak respiratory muscles plus infection. The other two options either ignore the timing of fatigability or create a dangerous medication error.

| Intervention | Rationale | Correct? |
| --- | --- | --- |
| Meals 45 minutes after pyridostigmine | Peak drug effect supports chewing and swallowing; reduces aspiration risk | Yes |
| Bath and walk in late evening | Weakness worsens with activity and late in the day; demanding tasks should be scheduled earlier | No |
| Suction and bag-valve mask at bedside | Bulbar and respiratory weakness can progress rapidly, especially with infection | Yes |
| Double dose for a missed pyridostigmine dose | Risk of cholinergic crisis; missed doses are never doubled | No |

Clinical application for the nursing licensure exam

The exam frequently tests the distinction between myasthenic crisis (too little acetylcholine, often from undermedication or infection) and cholinergic crisis (too much acetylcholine, often from overmedication). Both can present with severe weakness and respiratory distress. A key discriminator is that cholinergic crisis includes excessive muscarinic signs such as salivation, lacrimation, diarrhea, and bradycardia, while myasthenic crisis does not. Key point! When the cause is unclear, the safest immediate action is to protect the airway and support ventilation, not to give more pyridostigmine. In this scenario, the presence of fever and productive cough strongly suggests infection is worsening the MG, so respiratory support equipment at the bedside is essential. The nursing priority is to prevent aspiration and maintain a patent airway while the underlying infection is treated.

## 임상 시나리오

Myasthenia Gravis Nursing PrioritiesTiming medications and preparing for respiratory decline
Give pyridostigmine 30 to 60 minutes before meals so peak drug effect coincides with chewing and swallowing effort, reducing aspiration risk.

Keep suction and a bag-valve mask at the bedside because bulbar and respiratory weakness can progress rapidly, especially during infection or fever.

Schedule demanding activities such as bathing and walking for earlier in the day when strength is greatest, not late evening when fatigable weakness peaks.

CautionNever double a missed pyridostigmine dose; overdosing can trigger cholinergic crisis with worsening weakness and respiratory distress.

## 핵심 개념

- **myasthenia gravis** — autoimmune disorder causing fluctuating, fatigable weakness of voluntary muscles due to acetylcholine receptor antibodies
- **pyridostigmine** — acetylcholinesterase inhibitor that increases acetylcholine availability at the neuromuscular junction, peaking 30-60 minutes after oral dose
- **myasthenic crisis** — acute worsening of MG weakness leading to respiratory failure, often triggered by infection or fever
- **cholinergic crisis** — excess acetylcholine from overmedication causing muscle weakness, respiratory distress, and parasympathetic symptoms
- **bulbar weakness** — weakness of muscles controlling speech, chewing, and swallowing, increasing aspiration risk

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