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.

Nursing Test Bank

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

Explanation

Choice A rationale: While the temperature is important in assessing health, it isn't the most concerning finding in this scenario compared to others.

Choice B rationale: A thready pulse (a weak, barely palpable pulse) could indicate a critical drop in blood pressure and cardiac output, which is a significant concern.

Choice C rationale: While indicating a possible issue with hydration, it's not as immediately concerning as other findings in this context.

Choice D rationale: Recently lost his job - While this has social and economic implications, it's not an immediate physiological concern in this clinical scenario.

Choice E rationale: While significant in his overall health, it's not a direct finding from the current assessment that immediately raises concern.

A. Propranolol (Inderal) B. Ranitidine (Zantac) C. Atorvastatin (Lipitor) D. Metformin (Glucophage)

Correct Answer is A

Explanation

Choice A rationale: Propranolol, a beta-blocker used for high blood pressure and other cardiovascular conditions, is known to have potential side effects of sexual dysfunction, including erectile dysfunction (ED).

Choice B rationale: Ranitidine (Zantac) is an H2 blocker used for acid reflux and isn't typically associated with causing ED.

Choice C rationale: Atorvastatin (Lipitor), a statin used for high cholesterol, isn't commonly associated with causing ED.

Choice D rationale: Metformin (Glucophage), used for type 2 diabetes, is not typically linked to causing ED.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse cares for a client with diabetes mellitus and congestive heart failure. Exhibits Which two (2) client findings in the history and physical are most concerning? Select all that apply

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

Explanation

A 49-year-old man who has type 2 diabetes, high blood pressure, hyperlipidemia, and gastroesophageal reflux tells the nurse that he has had recent difficulty in achieving an erection. Which of the following drugs from his current medications list may cause erectile dysfunction (ED)?

Correct Answer is A

Explanation

The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action should be included in the plan of care?

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, how should the nurse report the response?

A client is admitted to the hospital with a traumatic brain injury after his head violently struck a brick wall during a gang fight. Which finding is most important for the nurse to assess further?

A 21-year-old college student has come to see the nurse practitioner for treatment of a vaginal infection. Physical assessment reveals inflammation of the vagina and vulva, and vaginal discharge has a cottage cheese appearance. These findings are consistent with:

While performing the genital assessment of a male client, a nurse observes that the client has curvature of the penis. Which condition does the nurse suspect in the client?

The nurse is most likely to report which finding to the primary care provider for a client who has an established colostomy?

After a breast examination, the nurse is documenting assessment findings that indicate possible breast cancer. Which abnormal findings need to be included as part of the client's electronic medical record? (Select all that apply.)