Jane, a 20-year old college student is admitted to the hospital with a tentative diagnosis of myasthenia gravis. She is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon test. In preparing her for this procedure, the nurse explains that her response to the medication will confirm the diagnosis if Tensilon produces:
The client shows a marked improvement of muscle strength.
The client has muscles become weakened due to the impaired ability to respond to nerve signals
There is reduced amplitude of electrical stimulation in the muscle.
The anti-acetylcholine receptor antibodies are present.
The Correct Answer is A
Choice A rationale: The Tensilon test involves injecting edrophonium, and in myasthenia gravis, temporary improvement in muscle strength confirms the diagnosis by demonstrating increased acetylcholine activity at the neuromuscular junction.
Choice B rationale: This describes the pathophysiology of myasthenia gravis but doesn’t directly confirm the diagnosis via the Tensilon test.
Choice C rationale: While this may be seen in myasthenia gravis, the Tensilon test specifically aims to observe improved muscle strength after administration.
Choice D rationale: While the presence of these antibodies is a characteristic of myasthenia gravis, the Tensilon test is used to assess the immediate response to the medication for diagnostic confirmation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: This symptom typically indicates secondary syphilis, not gonorrhea.
Choice B rationale: Warts on the genitals suggest a different sexually transmitted infection caused by HPV, not gonorrhea.
Choice C rationale: A discharge from the penis is a common symptom of gonorrhea and often prompts individuals to seek medical attention.
Choice D rationale: While discomfort can be associated with gonorrhea, the primary presenting symptom often involves discharge rather than specific lesions.
Correct Answer is A
Explanation
Choice A rationale: This patient is likely experiencing hyperosmolar hyperglycemic state (HHS). Rapid administration of IV fluids is crucial to correct severe dehydration associated with HHS.
Choice B rationale: Routine insulin therapy and exercise might be components of diabetes management but wouldn't directly address the immediate concern of severe dehydration and high blood glucose.
Choice C rationale: Cardiac monitoring for potassium changes might be necessary but isn't the primary immediate intervention for HHS.
Choice D rationale: Administering a different antibiotic for the UTI is incorrect, because there is no evidence that the current antibiotic is ineffective or causing adverse effects. The UTI may have triggered the HHS, but it is not the main problem that needs to be addressed urgently.
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