Physiological Adaptation Q 12

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The nursing assistant reports to you, the RN, that the patient with myasthenia gravis (MG) has an elevated temperature (102.20 F), heart rate of 120/minute, rise in blood pressure (158/94), and was incontinent of urine and stool. What is your best first action at this time?

  

     A. Administer an acetaminophen suppository

     B. Notify the physician immediately

     C. Recheck vital signs in 1 hour

     D. Reschedule patient’s physical therapy session

    

    

Correct Answer: B. Notify the physician immediately.

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The changes that the nursing assistant is reporting are characteristics of myasthenia crisis, which often follows some type of infection. The patient is at risk for inadequate respiratory function. In addition to notifying the physician, the nurse should carefully monitor the patient’s respiratory status. The patient may need intubation and mechanical ventilation.

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Option A: The nurse would notify the physician before giving the suppository because there may be orders for cultures before giving acetaminophen.

Option C: This patient’s vital signs need to be re-checked sooner than 1 hour.

Option D: Rescheduling the physical therapy can be delegated to the unit clerk and is not urgent. Focus: Prioritization

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