Jane, a 20-year old college student is admitted to the hospital with a tentative diagnosis of myasthenia gravis. She is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon test. In preparing her for this procedure, the nurse explains that her response to the medication will confirm the diagnosis if Tensilon produces:

The client shows a marked improvement of muscle strength.

The client has muscles become weakened due to the impaired ability to respond to nerve signals

There is reduced amplitude of electrical stimulation in the muscle.

The anti-acetylcholine receptor antibodies are present.

Answer and Explanation

The Correct Answer is A

Choice A rationale: The Tensilon test involves injecting edrophonium, and in myasthenia gravis, temporary improvement in muscle strength confirms the diagnosis by demonstrating increased acetylcholine activity at the neuromuscular junction.

Choice B rationale: This describes the pathophysiology of myasthenia gravis but doesn’t directly confirm the diagnosis via the Tensilon test.

Choice C rationale: While this may be seen in myasthenia gravis, the Tensilon test specifically aims to observe improved muscle strength after administration.

Choice D rationale: While the presence of these antibodies is a characteristic of myasthenia gravis, the Tensilon test is used to assess the immediate response to the medication for diagnostic confirmation.

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Correct Answer is ["B","C","D","E"]

Explanation

Choice A rationale: This is a normal value, indicating normal renal function. The client does not have any signs of kidney damage or impairment.

Choice B rationale: This is an elevated value, indicating an infection or inflammation in the body. Acute appendicitis is a common cause of increased white blood cells, as the appendix becomes inflamed and infected. This finding requires immediate follow-up to monitor the client's condition and prevent complications such as perforation or peritonitis.

Choice C rationale: This is a high value, indicating impaired renal function or dehydration. The client may have decreased urine output due to vomiting and fluid loss, or may have underlying kidney problems. This finding requires immediate follow-up to assess the client's hydration status and renal function, and to provide appropriate fluid and electrolyte replacement.

Choice D rationale: This is a sign of peritoneal irritation, which may indicate that the appendix has ruptured or is close to rupturing. This is a medical emergency that requires immediate surgical intervention to remove the appendix and prevent sepsis and shock.

Choice E rationale: This is a low value, indicating hypokalemia or low potassium levels in the blood. The client may have lost potassium due to vomiting and fluid loss, or may have underlying electrolyte imbalances. This finding requires immediate follow-up to assess the client's cardiac function and muscle strength, and to provide appropriate potassium supplementation.

Choice F rationale: These are common symptoms of acute appendicitis, as the inflammation and infection of the appendix cause irritation of the gastrointestinal tract. These symptoms do not require immediate follow-up, but they should be managed with antiemetics and fluids to prevent dehydration and electrolyte imbalances.

A. Impaired physical mobility related to decreased motor agility secondary to ALS as manifested by inability to ambulate. B. Hopelessness related to impaired ability to cope. C. Caregiver role strain related to care recipient's unrealistic expectations of caregiver. D. Impaired memory related to reduced quality and quantity of information processed.

Correct Answer is A

Explanation

Choice A rationale: In ALS, impaired physical mobility due to decreased motor agility and the inability to ambulate is a direct consequence of the disease.

Choice B rationale: Hopelessness might be a possible emotional response but doesn't address the client's physical limitations due to ALS.

Choice C rationale: Caregiver role strain is related to the family's ability to manage caregiving responsibilities and is not the primary concern for the client's physical mobility.

Choice D rationale: Impaired memory is not the primary issue in ALS; the client's inability to ambulate due to decreased motor function is the main focus for this nursing diagnosis.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who presents with acute appendicitis: Exhibits Select all that apply?

Correct Answer is ["B","C","D","E"]

Explanation

Correct Answer is A

Explanation

After reviewing the laboratory reports of a client, a nurse finds that the client has chronic pelvic inflammatory disorder (PID). Which condition should the nurse anticipate in the client?

The nurse is reviewing the record of a female client with Crohn's disease. Which stool characteristics should the nurse expect to note documented in the client's record?

The nurse is caring for a client who has ascites and hepatic encephalopathy. Which of the following prescriptions should the nurse clarify with the primary healthcare provider (PHCP)?

A nurse is developing a plan of care for a client with a new diagnosis of Graves' disease. Which of the following interventions does the nurse include in the plan of care?

Which type of epileptic seizure is characterized by a sudden lapse of consciousness for 5 to 30 seconds?

Which is a major side effect of radioactive iodine treatment for hyperthyroidism?