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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. Nicardipine is a calcium channel blocker primarily used to manage blood pressure but does not directly reduce ICP.
B. Phenytoin is an anticonvulsant used to prevent seizures, which may occur after a hemorrhage, but it does not address increased ICP.
C. Dopamine is used to increase blood pressure and cardiac output but does not play a role in reducing ICP.
D. Mannitol is an osmotic diuretic that helps decrease ICP by drawing fluid from brain tissue into the bloodstream, thus relieving pressure within the skull. It is the most appropriate intervention for managing increased ICP.

A. Apply a cooling blanket B. Monitor daily weight C. Provide opioid medications on an as needed basis D. PTT levels

Correct Answer is B

Explanation

A. A cooling blanket is not typically needed unless there is a fever or postoperative temperature dysregulation, which is not a standard intervention in this case.
B. Monitoring daily weight is essential following valve replacement to detect fluid retention or heart failure, which can indicate compromised cardiac function.
C. Opioid medications may be necessary, but they should be prescribed according to the client’s pain needs rather than a routine intervention.
D. PTT levels are usually monitored for clients on anticoagulants, but since the client has a biologic valve, anticoagulation therapy is not always required as with mechanical valves.

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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?

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