A nurse is caring for a client who is scheduled for a Tensilon challenge test to check for myasthenia gravis. Which of the following findings should the nurse identify as a positive result?
Muscle strength becomes temporarily stronger.
A "pill-rolling" tremor appears.
Electrical charge in the muscle increases in intensity.
Muscle strength shows no change.
The Correct Answer is A
A. A positive result in a Tensilon test is indicated by a temporary improvement in muscle strength following the administration of edrophonium (Tensilon), confirming the diagnosis of myasthenia gravis.
B. A "pill-rolling" tremor is associated with Parkinson's disease, not myasthenia gravis, and is not relevant to this test.
C. While muscle electrical activity can be assessed in other tests, the Tensilon test specifically evaluates muscle strength changes, not electrical charge intensity.
D. No change in muscle strength would suggest a negative result for myasthenia gravis, indicating that the test did not confirm the diagnosis.
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Related Questions
Correct Answer is B
Explanation
A. Primary progressive multiple sclerosis is characterized by a gradual progression of symptoms without relapses, so this does not match the client's pattern.
B. Relapsing-remitting multiple sclerosis is defined by episodes of exacerbation (active symptoms) followed by periods of remission (no symptoms), which aligns with the client's description.
C. Secondary progressive multiple sclerosis follows an initial relapsing-remitting course but leads to a more continuous decline in function, so it does not match the pattern described.
D. Clinically isolating syndrome refers to a single episode of neurological symptoms but does not indicate the pattern of relapses and remissions typical of relapsing-remitting multiple sclerosis.
Correct Answer is C
Explanation
A. The headache is not related to anxiety but is a known side effect of nitroglycerin due to vasodilation.
B. An allergy to nitroglycerin typically presents as a rash or breathing difficulty, not a headache.
C. Nitroglycerin commonly causes headaches due to the dilation of blood vessels in the brain, which usually lessens over time as the body adjusts.
D. A headache does not indicate tolerance to the medication. Tolerance develops when the body becomes less responsive to the medication's effects, which usually involves a reduced effect on chest pain, not the onset of a headache.
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