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 A

Explanation

A) Peaked T waves:
Peaked T waves are a classic sign of hyperkalemia on an EKG. As potassium levels rise, the T waves become taller, more pointed, and narrow, indicating changes in the heart's electrical conduction. This is one of the earliest and most characteristic EKG changes seen with hyperkalemia. Hyperkalemia can result from conditions such as kidney dysfunction, use of potassium-sparing diuretics, or other electrolyte imbalances.

B) Inverted P waves:
Inverted P waves typically suggest issues such as atrial ischemia or ectopic atrial rhythms but are not a hallmark sign of hyperkalemia. They may also appear with other conditions, like atrial fibrillation or atrial flutter. However, inverted P waves are not typically linked to elevated potassium levels.

C) Widened QRS:
A widened QRS complex can occur in several conditions, including hyperkalemia, but it is generally seen in more severe cases. As potassium levels rise further, the QRS complex may widen due to delayed conduction through the ventricles. Although a widened QRS can indicate hyperkalemia, it is a later sign, and it typically occurs after more specific changes like peaked T waves.

D) Prominent U wave:
Prominent U waves are more often associated with hypokalemia (low potassium levels) rather than hyperkalemia. U waves are typically seen after the T wave on the EKG and can be more prominent in conditions of low potassium.

A. Assess the client's potassium level. B. Check the client's temperature. C. Increase the client's oxygen flow rate to 15 L/min. D. Encourage the client to perform pursed-lip breathing.

Correct Answer is D

Explanation

A) Assess the client's potassium level:
While electrolyte imbalances, including low potassium, can contribute to symptoms like restlessness or muscle weakness, it is not the first priority in a client with COPD who suddenly becomes restless and anxious. Restlessness and anxiety in this context are more likely to be due to hypoxia (low oxygen levels), hypercapnia (high carbon dioxide levels), or respiratory distress.

B) Check the client's temperature:
An elevated temperature may indicate an infection, such as pneumonia or a respiratory tract infection, which can exacerbate COPD symptoms. However, in the context of sudden restlessness and anxiety, this is less likely to be the most immediate cause. The primary concern should be addressing the potential respiratory issues, such as hypoxia or acute exacerbation, rather than focusing on fever, unless other signs of infection are present.

C) Increase the client's oxygen flow rate to 15 L/min:
While it is important to ensure adequate oxygenation in a client with COPD, increasing the oxygen flow rate to 15 L/min may not be appropriate, as COPD patients are typically at risk for oxygen-induced hypercapnia. These patients often rely on low levels of oxygen to stimulate breathing, and administering high-flow oxygen can suppress their respiratory drive, potentially worsening carbon dioxide retention.

D) Encourage the client to perform pursed-lip breathing:
Pursed-lip breathing is a highly effective technique for COPD patients to help increase oxygenation and decrease the work of breathing. This technique involves the client breathing in through the nose and exhaling slowly through pursed lips, which helps to keep the airways open longer and facilitates the removal of trapped air in the lungs.

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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:

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Explanation

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Correct Answer is D

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