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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: This statement could indicate that the client is receiving too much dose of the medication, which can cause hyperthyroidism. Hyperthyroidism is a condition where the thyroid gland produces too much thyroid hormone, which can speed up the body's metabolism and cause symptoms such as tremors, nervousness, weight loss, increased heart rate, and heat intolerance.
Choice B rationale: More frequent bowel movements could be a normal effect of the medication, as levothyroxine can improve constipation that is often associated with hypothyroidism.
Choice C rationale: The ability to enjoy cold weather might suggest improved tolerance to cold, which would align with normalized thyroid function.
Choice D rationale: This could be a sign of improved well-being and quality of life due to the medication, as levothyroxine can improve fatigue and depression that are often associated with hypothyroidism.
Correct Answer is D
Explanation
Choice A rationale: This is a possible sign of TBI but is not necessarily indicative of a life- threatening condition.
Choice B rationale: This is a possible sign of TBI but is not necessarily indicative of a life- threatening condition.
Choice C rationale: This is a possible sign of TBI but is not necessarily indicative of a life- threatening condition.
Choice D rationale: Serosanguineous nasal drainage (a mixture of blood and clear fluid) may suggest a basilar skull fracture, which is a fracture of the base of the skull that can damage vital structures such as the brainstem, cranial nerves, or major blood vessels. This can lead to serious complications such as meningitis, cerebrospinal fluid leak, or hemorrhage.
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