A client with history of myasthenia gravis is experiencing prolonged periods of weakness and difficulty breathing. The provider orders an edrophonium [Tensilon] test. Once the dose is administered, the client becomes weaker. The nurse interprets this test result as:

A normal finding.

A myasthenia gravis crisis due to drug undermedication

An allergic reaction.

A cholinergic crisis due to drug overmedication

Answer and Explanation

The Correct Answer is D

A) A normal finding:
A normal finding during an edrophonium (Tensilon) test is an improvement in muscle strength for clients with myasthenia gravis (MG). If the client becomes weaker after the dose, it indicates that the test results are not typical and suggest a different issue, not a normal response. This is not a normal finding.

B) A myasthenia gravis crisis due to drug undermedication:
In a myasthenic crisis, the client experiences severe weakness and respiratory difficulty, typically due to insufficient medication (e.g., pyridostigmine). While a myasthenic crisis could cause weakness and respiratory distress, the edrophonium test would typically show improvement in muscle strength if the crisis is due to undermedication. Since the client became weaker after receiving edrophonium, this is not indicative of a myasthenic crisis.

C) An allergic reaction:
An allergic reaction to the edrophonium test would typically result in symptoms such as rash, swelling, or difficulty breathing due to hypersensitivity, but it does not typically cause weakness as the primary response. The worsening of symptoms after the test is more likely related to drug overmedication rather than an allergic reaction.

D) A cholinergic crisis due to drug overmedication:
A cholinergic crisis occurs when there is an overdose of acetylcholinesterase inhibitors (e.g., pyridostigmine or neostigmine), which can lead to excessive acetylcholine at the neuromuscular junction, resulting in muscle weakness and respiratory failure. The edrophonium test helps differentiate between a myasthenic crisis and a cholinergic crisis. If the client becomes weaker after the administration of edrophonium, it suggests a cholinergic crisis due to drug overmedication.

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

Explanation

A) Stop taking ordered corticosteroid once symptoms resolve:
Corticosteroids, such as prednisone, are commonly prescribed to reduce inflammation in Bell’s Palsy, especially during the acute phase. However, it is important to complete the full course of corticosteroids as prescribed, even if symptoms improve. Abruptly stopping corticosteroids can lead to rebound inflammation and potentially worsen the condition.

B) Apply warm compresses to the affected area several times a day:
Warm compresses can help to reduce pain and inflammation in the affected side of the face. Applying them several times a day can also help improve circulation and ease the discomfort associated with Bell's Palsy. This is a recommended self-care strategy that can help provide relief and improve overall comfort for the client during recovery.

C) Cover the affected eye with an eye protective shield or patch at night:
Bell's Palsy can lead to paralysis of the facial muscles, which may make it difficult for the client to fully close the eyelid on the affected side, leaving the eye vulnerable to dryness and injury. Covering the eye with a protective shield or patch at night helps prevent corneal damage and protects the eye from exposure during sleep. This is an essential part of eye care for a client with Bell’s Palsy to prevent complications.

D) Chew food only on the affected side:
There is no medical recommendation to limit chewing to the unaffected side. In fact, clients should be encouraged to use both sides of their mouth for chewing to prevent muscle atrophy and maintain function. There is no evidence to support that chewing food only on the affected side provides any benefit.

E) Place artificial tears or lubricant to help decrease dryness in the eyes:
Since Bell's Palsy can impair the ability to close the eyelid fully, this can lead to dryness and potential corneal damage on the affected side. Artificial tears or lubricating eye drops should be used regularly to moisturize the eye and prevent complications such as corneal ulcers or abrasions.

A. Have the client swish with commercial mouthwash before therapy. B. Place fresh flowers in the clients room C. Tell the client to expect dark stools following chemotherapy. D. Administer an antiemetic prior to the procedure.

Correct Answer is D

Explanation

A) Have the client swish with commercial mouthwash before therapy:
Some commercial mouthwashes contain alcohol, which can be irritating to the mucous membranes, especially in clients undergoing chemotherapy. Chemotherapy can cause mucositis or stomatitis, making the oral cavity more sensitive, so alcohol-based mouthwashes should be avoided

B) Place fresh flowers in the client's room:
Fresh flowers are not recommended in the rooms of clients undergoing chemotherapy because they can introduce bacteria into the environment, which is particularly concerning for clients with weakened immune systems due to chemotherapy. Chemotherapy suppresses the immune system, increasing the risk of infection.

C) Tell the client to expect dark stools following chemotherapy:
Chemotherapy can cause a variety of gastrointestinal side effects, but dark stools are not a typical or expected side effect. Dark stools may indicate gastrointestinal bleeding, which requires immediate attention.

D) Administer an antiemetic prior to the procedure:
Chemotherapy commonly causes nausea and vomiting, and preemptive administration of antiemetic medications can help prevent these symptoms. The nurse should follow the healthcare provider's orders and administer antiemetics as prescribed, which can significantly improve the client's comfort and adherence to the treatment plan.

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A client with history of myasthenia gravis is experiencing prolonged periods of weakness and difficulty breathing. The provider orders an edrophonium [Tensilon] test. Once the dose is administered, the client becomes weaker. The nurse interprets this test result as:

Nursing Test Bank

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Explanation

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Correct Answer is D

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