A patient with myasthenia gravis experiences dysphagia. What is the priority risk associated with dysphagia that must be considered when planning nursing care?

1. A

   Aspiration

2. B

   Dehydration

3. C

   Malnutrition

4. D

   Gastric ulcer

Appeared in: ISRO 2024

Explanation

• Myasthenia gravis is a neuromuscular disorder that causes weakness in voluntary muscles, including the bulbar muscles responsible for swallowing.
• Dysphagia (difficulty swallowing) is a common symptom when these muscles are affected.
• The highest priority risk associated with dysphagia is aspiration, which is the entry of food or liquid into the trachea and lungs.
• Aspiration can lead to immediate choking and airway obstruction or develop into aspiration pneumonia, a life-threatening infection.
• Nursing care must prioritize maintaining a patent airway, making aspiration the most critical risk to address.

Why Other Options Were Wrong

• Option B: Dehydration is a potential complication of dysphagia due to decreased fluid intake, but it is a subacute or chronic issue, not an immediate life-threat like aspiration.
• Option C: Malnutrition results from prolonged inadequate food intake. Like dehydration, it is a serious long-term consequence but does not take priority over the acute danger of a compromised airway.
• Option D: Gastric ulcers are not a direct or common complication of dysphagia or myasthenia gravis. They have different etiologies, such as bacterial infection or medication side effects.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Priority nursing risk for dysphagia in myasthenia gravis to guide bedside assessment, documentation, and the next nursing action.
• In nursing, the ABC (Airway, Breathing, Circulation) framework is always used to prioritize care. Aspiration is a direct threat to the airway, making it the top priority.
• Nurses must assess for signs of dysphagia, such as coughing during meals, a gurgly voice, or pocketing food, and implement aspiration precautions immediately.
• Key interventions include positioning the patient upright, modifying diet consistency (thickened liquids, pureed foods), and having suction equipment ready at the bedside.

How to Approach the Question

• First, identify the core concepts in the question: the patient has Myasthenia Gravis (a muscle weakness disease) and Dysphagia (difficulty swallowing).
• The keyword is 'priority risk'. This signals that you must choose the most immediate and life-threatening option.
• Apply the ABC (Airway, Breathing, Circulation) framework. Ask yourself which of the options poses the most direct threat to the patient's airway.
• Evaluate the options: Aspiration directly affects the airway. Dehydration and malnutrition are serious but develop over time. Gastric ulcer is unrelated.
• Conclude that aspiration is the highest priority because it can cause immediate choking or lead to severe respiratory complications like pneumonia.
• Select the option that aligns with protecting the airway as the first priority in nursing care.

Concept Tested & Keywords

• Concept Tested: Priority nursing risk for dysphagia in myasthenia gravis.
• Stem keywords: myasthenia gravis, dysphagia, priority risk, nursing care
• Lead-in keywords: priority
• Clinical cues: Diagnosis: Myasthenia Gravis - This points to potential neuromuscular weakness affecting swallowing.
• Clinical cues: Symptom: Dysphagia - This signals a problem with the swallowing mechanism, immediately raising concern for airway safety.

Question ID

QVAto65lJi6l9dlZfxDbGT

Copy ID

Reference Book

E6 Nursing Fundamentals Potter Perry 12e Part 5 pp. 192-194, 212-214