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","D"]

Explanation

A) Use a razor to shave the hair in the treated area:
Shaving the treated area with a razor is not recommended during radiation therapy. The skin in the treated area becomes sensitive and fragile, so shaving could cause irritation, cuts, or abrasions. Instead, clients are usually advised to use electric razors or avoid shaving the area altogether. This instruction should not be followed to minimize the risk of injury.

B) Wash treated area gently with lukewarm water and mild soap:
This is a key self-care instruction for clients receiving radiation. Gentle cleansing with lukewarm water and mild soap helps to avoid further irritation to the skin, which can become dry and sensitive during radiation therapy. The treated area should not be scrubbed or rubbed, as this can cause damage to the skin, exacerbate dryness, or cause skin breakdown. This guideline is appropriate and should be followed.

C) Purchase aloe-approved skin-care products:
Using aloe vera or skin-care products approved for use during radiation therapy can help soothe and moisturize the skin, which often becomes dry, irritated, or sunburned from radiation. It is important to use products that are specifically designed for use during radiation to avoid any potential irritants or allergens. Aloe-based products or products recommended by the healthcare provider can provide relief and reduce side effects.

D) Wear loose-fitting, soft clothing over the treated skin:
Wearing loose-fitting, soft clothing is a crucial self-care recommendation for clients undergoing radiation. Tight or rough fabrics can irritate the sensitive skin, potentially leading to discomfort or skin breakdown. Soft fabrics like cotton are ideal, as they allow the skin to breathe and help avoid further friction or pressure on the treated area. This is an important aspect of skin protection during radiation therapy.

E) Sun tan the affected area for no more than 30 minutes a day:
Sun tanning or exposing the treated skin to direct sunlight is strictly forbidden during and after radiation therapy. The skin in the treated area is much more sensitive to UV radiation and can burn easily, even with minimal sun exposure. It can increase the risk of skin damage and delayed healing. The client should be advised to avoid direct sun exposure entirely and to wear protective clothing and sunscreen if they must be outdoors.

A. Administering oral antibiotics to a client with UTI. B. Teaching a client with a new order for a renal angiogram. C. Evaluate the outflow of peritoneal diasylate. D. Assess a client with flank pain due to glomerulonephritis.

Correct Answer is A

Explanation

A) Administering oral antibiotics to a client with UTI:
Administering oral antibiotics is an appropriate task to delegate to a licensed practical nurse (LPN). LPNs are trained to administer medications, including oral antibiotics, and to monitor for common side effects or adverse reactions. Since the task is routine and does not require advanced clinical judgment, it can be delegated to the LPN under the nurse’s supervision.

B) Teaching a client with a new order for a renal angiogram:
Teaching a client about a new diagnostic procedure, such as a renal angiogram, requires advanced knowledge and clinical judgment to explain the procedure, its risks, and the necessary pre- and post-procedure care. This task is best performed by a registered nurse (RN) because it involves providing detailed patient education and addressing the patient’s concerns.

C) Evaluate the outflow of peritoneal dialysate:
Evaluating the outflow of peritoneal dialysate is a more complex task that involves assessing the effectiveness of the dialysis process and identifying any potential complications (e.g., infection, leakage). This task requires clinical expertise in dialysis and the ability to interpret changes in the output. Although LPNs may assist in monitoring the process, it is ultimately the RN’s responsibility to evaluate the outcome, interpret any changes, and intervene if necessary.

D) Assess a client with flank pain due to glomerulonephritis:
Assessment of a client with flank pain related to glomerulonephritis requires a thorough evaluation of the client's condition, including understanding the potential causes of pain and monitoring for complications such as renal failure or infection. This type of assessment requires critical thinking and clinical judgment, making it the responsibility of the RN.

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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

Naxlex Comprehensive Predictor Exams

A nurse discusses the self-care guidelines to minimize the side effects of radiation on the skin. Which self-care instructions can the nurse provide the client receiving radiation? [Select all that apply.]

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

Explanation

A nurse is caring for a group of clients on a hospital unit with the assistance of a licensed practical nurse [LPN]. Which aspect of client care would be the most appropriate for the nurse to delegate to the LPN?

Correct Answer is A

Explanation

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