A nurse is caring for a client who is scheduled for a Tensilon challenge test to check for myasthenia gravis. Which of the following findings should the nurse identify as a positive result?

Muscle strength becomes temporarily stronger.

A "pill-rolling" tremor appears.

Electrical charge in the muscle increases in intensity.

Muscle strength shows no change.

Answer and Explanation

The Correct Answer is A

A. A positive result in a Tensilon test is indicated by a temporary improvement in muscle strength following the administration of edrophonium (Tensilon), confirming the diagnosis of myasthenia gravis.
B. A "pill-rolling" tremor is associated with Parkinson's disease, not myasthenia gravis, and is not relevant to this test.
C. While muscle electrical activity can be assessed in other tests, the Tensilon test specifically evaluates muscle strength changes, not electrical charge intensity.
D. No change in muscle strength would suggest a negative result for myasthenia gravis, indicating that the test did not confirm the diagnosis.

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Correct Answer is B

Explanation

A. Shopping for shoes in the morning is not recommended, as feet tend to swell later in the day, and shoe fitting should account for potential swelling.
B. Incorporating walking into the daily routine helps improve circulation and can aid in managing peripheral vascular disease by promoting blood flow in the legs.
C. Elevating the legs might decrease circulation and is not advised for clients with peripheral vascular disease, as it can reduce blood flow to the extremities.
D. Knee-length stockings can restrict circulation, especially if they are too tight, and should be avoided to promote proper blood flow in clients with this condition.

A. Ambulation pattern B. Muscle movements C. Speech D. Orientation status E. Facial rigidity

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B,C"},"E":{"answers":"A"}}

Explanation

Assessment Findings and Rationale

1. Ambulation Pattern

Parkinson's Disease: The slow and shuffling gait is characteristic of Parkinson's disease due to muscle rigidity and bradykinesia (slowness of movement). Patients often exhibit a stooped posture and a shuffling gait.

2. Muscle Movements

Parkinson's Disease: Unilateral resting tremors and generalized muscle stiffness are hallmark signs of Parkinson's disease, which affects motor control due to basal ganglia degeneration. As the disease progresses, bilateral tremors and stiffness develop.

3. Speech

Parkinson's Disease: Slow and slurred speech is common in Parkinson's disease as a result of muscle rigidity affecting speech production.

Stroke: Speech difficulties such as slurred speech may also occur in stroke patients due to dysarthria, which arises from motor control deficits.

Multiple Sclerosis: Speech issues, including slurred speech, can also be seen in multiple sclerosis due to neurological involvement and muscle control issues.

4. Orientation Status

Parkinson's Disease: Disorientation to date and time can be seen in later stages of Parkinson's disease as cognitive decline may accompany the motor symptoms.

Stroke: Cognitive deficits, including disorientation, can result from stroke, especially if it affects the areas of the brain responsible for cognition.

Multiple Sclerosis: Orientation issues may also occur in multiple sclerosis as cognitive impairment can be part of the disease process.

5. Facial Rigidity

Parkinson's Disease: Facial rigidity, often described as a "masked face," is a classic symptom of Parkinson's disease, resulting from decreased facial muscle control.

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A nurse is caring for a client who is scheduled for a Tensilon challenge test to check for myasthenia gravis. Which of the following findings should the nurse identify as a positive result?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has peripheral vascular disease. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is caring for a client. Exhibits For each client finding, click to specify if the finding is consistent with Parkinson's disease, stroke, and/or multiple sclerosis. Each finding can support more than one disease process.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B,C"},"E":{"answers":"A"}}

Explanation

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