A nurse is caring for a client who has a suspected diagnosis of myasthenia gravis. The provider prescribes a Tensilon test. Which of the following findings indicates a positive test?
Muscle strength shows no change.
Muscle contractions become progressively stronger.
Electrical charge in a muscle increases in intensity.
A pill-rolling tremor appears.
The Correct Answer is B
A. If there is no change in muscle strength after the Tensilon test, it indicates a negative result for myasthenia gravis.
B. Muscle contractions become progressively stronger is a positive result for myasthenia gravis. Tensilon temporarily improves muscle strength in patients with this condition.
C. Electrical charge in a muscle increases in intensity is not a relevant parameter for the Tensilon test.
D. A pill-rolling tremor appears is a symptom of Parkinson's disease, not myasthenia gravis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. In DIC, there is actually a consumption of clotting factors rather than an increase. The widespread activation of the clotting cascade leads to the consumption of clotting factors and platelets as they are used up in forming numerous small blood clots throughout the body. This depletion results in a paradoxical bleeding tendency due to a shortage of clotting factors.
B. This is characteristic of DIC. The condition involves both excessive clotting (thrombosis) and bleeding. The formation of small clots throughout the microcirculation leads to organ damage and depletion of clotting factors and platelets, which in turn causes bleeding tendencies. This dual process of clot formation and bleeding is a hallmark of DIC.
C. In DIC, there is a decrease in platelet count, not an increase. The condition causes widespread clotting, which consumes platelets rapidly, leading to a low platelet count. Therefore, a progressive increase in platelet count would not be expected in DIC.
D. Sodium and fluid retention are not primary features of DIC. Instead, DIC typically presents with symptoms related to clotting and bleeding rather than fluid balance. Fluid retention would be more associated with other conditions like heart failure or renal disorders, not directly with DIC.
Correct Answer is ["A","C","E"]
Explanation
A. The client is experiencing apnea and has decreased oxygen saturation, indicating a need for supplemental oxygen.
B. Restraining a client during a seizure is dangerous and can cause injury.
C. This information is crucial for determining the type of seizure and guiding treatment.
D. Placing a tongue depressor in the client's mouth can cause trauma to the teeth and mouth and should never be done.
E. Turning the client to the side helps prevent aspiration of saliva or vomit, protecting the airway.
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