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. A cooling blanket is not typically needed unless there is a fever or postoperative temperature dysregulation, which is not a standard intervention in this case.
B. Monitoring daily weight is essential following valve replacement to detect fluid retention or heart failure, which can indicate compromised cardiac function.
C. Opioid medications may be necessary, but they should be prescribed according to the client’s pain needs rather than a routine intervention.
D. PTT levels are usually monitored for clients on anticoagulants, but since the client has a biologic valve, anticoagulation therapy is not always required as with mechanical valves.

A. Right groin area B. Left Groin area C. Right ankle D. Left ankle

Correct Answer is B

Explanation

A. The right groin area is not the site of the procedure, so placing a sandbag here would not help control bleeding or pressure.
B. The sandbag should be placed over the left groin area where the femoral artery was accessed during the angiography. This helps apply pressure to prevent bleeding from the site and promote clot formation.
C. The right ankle is irrelevant to the procedure and would not require pressure.
D. Similarly, the left ankle has no relation to the femoral angiography site.

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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

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