Which nursing diagnosis is of the highest priority when caring for a client with myasthenia Gravis?

Appeared in: DHS Staff Nurse - 2018 (Shift-2nd)

Explanation

The ABC (Airway, Breathing, Circulation) framework dictates that maintaining a patent airway is the highest priority.
Myasthenia Gravis causes weakness of the respiratory muscles (diaphragm, intercostals) and bulbar muscles (swallowing, coughing).
This weakness impairs the client's ability to manage secretions and maintain a clear airway, leading to a high risk of aspiration and respiratory failure.
A potential for respiratory failure (myasthenic crisis) is the most immediate life-threatening complication of MG.

Option A: Myasthenia Gravis is characterized by painless, fluctuating muscle weakness. Pain is not a typical or primary symptom of the disease itself.
Option B: While the risk for injury from falls or impaired vision (ptosis, diplopia) is a valid concern, it is a safety issue. According to prioritization principles, life-threatening airway and breathing problems must be addressed first.
Option C: Ineffective coping is a psychosocial diagnosis. While living with a chronic illness like MG can be emotionally challenging, physiological stability is always the priority over psychosocial needs.

Clinical Relevance

Nursing practice connection: Use the key finding related to Prioritization of nursing diagnoses for Myasthenia Gravis to guide bedside assessment, documentation, and the next nursing action.
Nurses must perform frequent respiratory assessments on clients with MG, monitoring respiratory rate, depth, oxygen saturation, and ability to handle secretions.
Emergency equipment, including a suction machine and intubation tray, should be kept at the bedside for a client at risk for myasthenic crisis.
Patient education is crucial, focusing on medication adherence, energy conservation techniques, and recognizing the signs of both myasthenic and cholinergic crises.

How to Approach the Question

First, identify the question type. This is a 'highest priority' question, which requires you to rank nursing diagnoses based on urgency and potential for harm.
Apply the ABC (Airway, Breathing, Circulation) framework. Scan the options to see if any relate to these three critical functions.
Analyze the pathophysiology of the condition mentioned (Myasthenia Gravis). Recall that it's a neuromuscular disease causing muscle weakness.
Connect the pathophysiology to the options. The muscle weakness in MG directly impacts the muscles for breathing and swallowing, making 'Ineffective airway clearance' a direct threat to life (an 'A' and 'B' problem).
Evaluate the other options. 'Risk for injury' is a safety issue, and 'Ineffective coping' is psychosocial. These are addressed after life-sustaining functions are secured.
Conclude that the airway-related diagnosis is the highest priority over safety and psychosocial needs.

Concept Tested & Keywords

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E6 Nursing Fundamentals Potter Perry 12e Part 2 p. 22-24

Practise the full DHS Staff Nurse - 2018 (Shift-2nd)

Attempt every question from this paper in a timed mock, then review the full solution for each one.