In myasthenia gravis, which finding is the highest priority for the nurse to monitor?

In myasthenia gravis, which finding is the highest priority for the nurse to monitor?

• A. Watch for respiratory paralysis (ineffective breathing pattern).
• B. Monitor for rash.
• C. Check for constipation.
• D. Assess for tachycardia.

Answer: (A)

In myasthenia gravis, weakness can involve the muscles used to breathe, including the diaphragm and intercostals. The biggest danger is respiratory failure, so the top nursing priority is closely monitoring breathing and airway status. Watch for signs of becoming unable to maintain ventilation: increasing shortness of breath, shallow or rapid breathing, changing voice or speech, poor cough with inability to clear secretions, use of accessory muscles, and decreasing oxygen saturation. Early detection of respiratory compromise allows prompt intervention, including airway support or mechanical ventilation if needed. Other findings like a rash, constipation, or tachycardia may occur but do not pose the same immediate risk to life as deteriorating breathing in this condition.

In myasthenia gravis, weakness can involve the muscles used to breathe, including the diaphragm and intercostals. The biggest danger is respiratory failure, so the top nursing priority is closely monitoring breathing and airway status. Watch for signs of becoming unable to maintain ventilation: increasing shortness of breath, shallow or rapid breathing, changing voice or speech, poor cough with inability to clear secretions, use of accessory muscles, and decreasing oxygen saturation. Early detection of respiratory compromise allows prompt intervention, including airway support or mechanical ventilation if needed. Other findings like a rash, constipation, or tachycardia may occur but do not pose the same immediate risk to life as deteriorating breathing in this condition.