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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. This is a realistic goal for a C5 injury. Patients can often develop the strength and coordination in their arms to use adaptive equipment like a mobile arm support or a built-up spoon to feed themselves.
B. This goal is generally not achievable with a C5 injury. Independent transfers require significant lower body strength and coordination, which are completely absent in this case.
C. This is a potential option, but it's not a rehabilitation goal. It's more of an adaptive equipment recommendation to assist with mobility and independence in tasks like operating computer or phone.

D. This is not a realistic goal for a complete spinal cord transection at C5. Bowel and bladder function are typically impaired below the level of injury.

A. Fluid overload- B. Hypovolemia C. Left ventricular failure D. Intracardiac shunt

Correct Answer is B

Explanation

A. A high CVP, not a low CVP, is typically associated with fluid overload.
B. A low CVP indicates decreased fluid volume, which is characteristic of hypovolemia. This is particularly relevant to a patient with multiple traumas who may have significant blood loss.
C. While left ventricular failure can contribute to hemodynamic instability, it's not directly correlated with a low CVP.
D. This would affect the oxygenation status of the blood, rather than the overall blood volume and CVP.

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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?

Nursing Test Bank

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