The nurse is assisting while a neurologist administers an edrophonium (Tensilon) test to a client with facial weakness and ptosis. If the test is positive for myasthenia gravis, which outcome would the nurse observe?

Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes.

After administration, the client will experience worsening facial weakness and ptosis.

After administration of the medication, there will be no change in the status of the ptosis or facial weakness.

The client will have elimination of symptoms lasting at least 24 hours after the administration of the medication.

Answer and Explanation

The Correct Answer is A

This is the correct expected outcome if the test is positive for myasthenia gravis. Edrophonium works quickly to increase acetylcholine levels, leading to temporary improvement in muscle strength. In a patient with myasthenia gravis, administration of edrophonium typically results in a rapid improvement in symptoms like facial weakness and ptosis within 30 to 60 seconds, with the effects lasting for a few minutes. This brief improvement is indicative of a positive result for myasthenia gravis.
B.A Worsening symptoms after administration of edrophonium are not expected and could indicate an adverse reaction or incorrect diagnosis. In myasthenia gravis, edrophonium typically improves symptoms rather than worsening them.
C. No change in symptoms would be unexpected in the case of myasthenia gravis. If edrophonium is effective, there should be a noticeable improvement in symptoms. If there is no change, it might suggest a diagnosis other than myasthenia gravis or that the test is inconclusive.
D. This outcome is not expected. Edrophonium has a very short duration of action, typically relieving symptoms for only a few minutes. The effects do not last for 24 hours. A longer-lasting improvement might be observed with other treatments for myasthenia gravis, such as anticholinesterase medications like pyridostigmine, but not with edrophonium.

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Correct Answer is C

Explanation

A. Gum bleeding can be a sign of thrombocytopenia (low platelet count) and is concerning because it indicates a potential for bleeding complications. However, while it's significant, it might not be the most urgent symptom in the context of HIT compared to symptoms indicating acute thrombosis.

B. A hemoglobin level of 14 g/dL is generally within the normal range for most adults. In the context of HIT, this level does not indicate any immediate abnormality or severe issue related to anemia or bleeding, making it less concerning compared to other symptoms that might indicate acute complications.
C. Tachycardia (increased heart rate) and shortness of breath are concerning symptoms in the context of HIT. These symptoms can be indicative of a thrombotic event such as a pulmonary embolism (PE) or deep vein thrombosis (DVT), which are serious complications of HIT. The presence of these symptoms requires urgent evaluation as they suggest possible life-threatening complications.
D. Petechiae are small, pinpoint red or purple spots that appear due to bleeding under the skin, often associated with low platelet counts. While petechiae are a concerning sign and indicate bleeding issues, the presence of tachycardia and shortness of breath generally represents a more immediate threat to the patient's life due to potential thromboembolic events.

A. Loss of central vision and distortion of lines B. Floaters and flashes of light C. Cloudy vision and glaring of lights D. Loss of peripheral vision

Correct Answer is A

Explanation

A. AMD affects the macula, which is responsible for central vision and fine detail. As the condition progresses, patients often experience a gradual loss of central vision, which can make it difficult to read, recognize faces, and perform tasks that require sharp vision. Distortion of straight lines (metamorphopsia) is also common, where straight lines may appear wavy or bent.
B. Floaters and flashes of light are more commonly associated with conditions affecting the vitreous body of the eye or retinal detachment, rather than AMD. These symptoms can occur due to changes in the vitreous gel or as a result of other retinal issues, but they are not the primary symptoms of AMD.
C. Cloudy vision and glare are typically associated with cataracts, not AMD. Cataracts cause the lens of the eye to become cloudy, leading to blurred vision and increased sensitivity to glare. AMD does not cause the lens to cloud, so these symptoms are not characteristic of AMD.
D. Loss of peripheral vision is more characteristic of glaucoma rather than AMD. AMD primarily affects central vision, leaving peripheral vision relatively intact until the disease progresses to an advanced stage. Glaucoma, on the other hand, often leads to a gradual loss of peripheral vision.

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The nurse is assisting while a neurologist administers an edrophonium (Tensilon) test to a client with facial weakness and ptosis. If the test is positive for myasthenia gravis, which outcome would the nurse observe?

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