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A nurse is caring for an adult patient with myasthenia gravis. Which of the following nursing diagnosis is a priority?

Explanation

• Extreme muscle weakness that increases with activity and decreases with rest is a feature of myasthenia gravis. The nurse must monitor the respiratory status of the patient frequently as this disease can greatly affect the respiratory muscles.

• Primary attention is given to airway clearance since a person with myasthenia gravis can develop respiratory muscle failure. 

• Incorrect: Ineffective coping may occur, but this is not the priority diagnosis over airway clearance. 

• Incorrect: Risk for injury in patients with myasthenia gravis is significant, but ineffective airway clearance takes higher importance (A-B-C!).

• Incorrect: Pain is not usually a major problem in patients with myasthenia gravis.

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