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 D
Explanation
Choice A rationale: This may indicate a different condition such as gastroenteritis rather than Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS).
Choice B rationale: This is more indicative of diabetic ketoacidosis (DKA) rather than HHNS.
Choice C rationale: A 72-year-old with a history of diabetes, elevated blood glucose, and complaints of thirst and frequent urination might have uncontrolled diabetes, but the absence of severe hyperglycemia and other symptoms specific to HHNS makes this choice less likely.
Choice D rationale: This fits the criteria for HHNS. The infection, missed medication, and extremely high blood glucose levels suggest the possibility of Hyperglycemic Hyperosmolar Nonketotic Syndrome.
Correct Answer is C
Explanation
Choice A rationale: Although important to assess for potential kidney injury, addressing hypotension due to potential spinal shock takes priority.
Choice B rationale: Important for determining any neurological deficits, but addressing hypotension is the initial priority.
Choice C rationale: Hypotension indicates potential spinal shock or hemorrhagic shock, and fluid resuscitation is the immediate priority to stabilize the client's blood pressure.
Choice D rationale: While important for assessing cardiac status, addressing hypotension takes precedence to stabilize the client's condition.
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