A patient with signs and symptoms of myasthenia gravis is scheduled to receive Tensilon (edrophonium chloride) for diagnostic purposes. Which of the following assessments should the nurse prioritize before administering this medication to assess the effectiveness of Tensilon?
Obtain a complete medication history including current prescriptions.
Evaluate for any signs of respiratory distress.
Check the patient's blood pressure and heart rate.
Assess the patient's muscle strength and endurance.
The Correct Answer is D
Rationale:
A. While it is important to review the patient’s medications to avoid drug interactions (e.g., with cholinergic or anticholinergic drugs), this is not the primary assessment to evaluate Tensilon’s effectiveness in diagnosing myasthenia gravis.
B. Respiratory status is critical to monitor due to the risk of respiratory compromise in myasthenia gravis or during a cholinergic crisis. However, prior to administering Tensilon for diagnostic purposes, the primary goal is to assess neuromuscular response, not respiratory function, although baseline respiratory assessment is part of overall safety.
C. Monitoring vital signs is necessary because edrophonium can cause bradycardia or hypotension, but these parameters do not measure the diagnostic effectiveness of the medication.
D. Tensilon works by temporarily inhibiting acetylcholinesterase, increasing acetylcholine at the neuromuscular junction. The diagnostic response is evaluated by observing improvement in muscle strength and endurance, typically in areas such as ptosis, facial muscles, or grip strength. Comparing pre- and post-administration muscle performance allows the nurse and provider to determine whether the patient has myasthenia gravis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Glucocorticoids do not improve muscle strength. In fact, long-term corticosteroid use can cause steroid-induced myopathy, which leads to muscle weakness, particularly in the proximal muscles of the thighs and shoulders. This side effect can reduce the patient’s overall physical function and mobility rather than enhancing it. Therefore, this is not an expected or beneficial effect of corticosteroid therapy.
B. Glucocorticoids are immunosuppressive, meaning they reduce the body’s ability to mount an immune response. This places the patient at increased risk of infections, including opportunistic infections. Patients should be educated to monitor for signs of infection such as fever, cough, sore throat, or unusual fatigue, and seek medical attention promptly if symptoms occur.
C. Corticosteroids affect carbohydrate, protein, and fat metabolism, which can lead to elevated blood glucose levels, particularly in patients with pre-existing diabetes or impaired glucose tolerance. They also cause fluid retention and increased vascular sensitivity to catecholamines, which can elevate blood pressure. Patients should monitor for symptoms such as increased thirst, frequent urination, fatigue, headaches, or swelling, and regularly check their blood pressure and glucose levels as recommended by their healthcare provider. This monitoring is essential to detect and manage complications early.
D. While glucocorticoids can reduce inflammation and alleviate pain during a flare-up, they do not directly improve joint mobility. Improvements in mobility are usually achieved through physical therapy, exercise, and long-term disease-modifying antirheumatic drugs (DMARDs) rather than corticosteroid therapy alone
Correct Answer is C
Explanation
Rationale:
A. These are common side effects of opioid use, not withdrawal. During withdrawal, gastrointestinal motility increases and alertness rises, leading to diarrhea, insomnia, and agitation rather than constipation and drowsiness.
B. While mild autonomic changes can occur, hypotension is not a hallmark of opioid withdrawal. Hyperactivity may be present in terms of restlessness, but this option does not capture the key constellation of withdrawal symptoms.
C. These are classic opioid withdrawal symptoms. Rhinitis (runny nose), yawning, lacrimation, abdominal cramping, diarrhea, restlessness, and agitation are signs of the sympathetic nervous system overactivity that occurs when opioids are abruptly discontinued or doses are missed. These symptoms guide nursing monitoring and support.
D. These are common effects of opioid overdose, not withdrawal. Withdrawal typically causes tachycardia, hypertension, and increased respiratory rate, reflecting sympathetic activation
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