The nurse is assisting while a neurologist administers an edrophonium (Tensilon) test to a client with facial weakness and ptosis. If the test is positive for myasthenia gravis, which outcome would the nurse observe?
Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes.
After administration, the client will experience worsening facial weakness and ptosis.
After administration of the medication, there will be no change in the status of the ptosis or facial weakness.
The client will have elimination of symptoms lasting at least 24 hours after the administration of the medication.
The Correct Answer is A
This is the correct expected outcome if the test is positive for myasthenia gravis. Edrophonium works quickly to increase acetylcholine levels, leading to temporary improvement in muscle strength. In a patient with myasthenia gravis, administration of edrophonium typically results in a rapid improvement in symptoms like facial weakness and ptosis within 30 to 60 seconds, with the effects lasting for a few minutes. This brief improvement is indicative of a positive result for myasthenia gravis.
B.A Worsening symptoms after administration of edrophonium are not expected and could indicate an adverse reaction or incorrect diagnosis. In myasthenia gravis, edrophonium typically improves symptoms rather than worsening them.
C. No change in symptoms would be unexpected in the case of myasthenia gravis. If edrophonium is effective, there should be a noticeable improvement in symptoms. If there is no change, it might suggest a diagnosis other than myasthenia gravis or that the test is inconclusive.
D. This outcome is not expected. Edrophonium has a very short duration of action, typically relieving symptoms for only a few minutes. The effects do not last for 24 hours. A longer-lasting improvement might be observed with other treatments for myasthenia gravis, such as anticholinesterase medications like pyridostigmine, but not with edrophonium.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A creatinine level of 1.2 mg/dL is within the upper range of normal but may be slightly elevated depending on the baseline level pre-transplant and individual patient factors. For a client 3 months post- transplant, this level could indicate stable kidney function or a mild increase but is not necessarily indicative of a significant complication.
B.A 24-hour urine output of 1,800 mL is within the normal range for adults (about 1,000 to 2,000 mL per day). This level of urine output suggests that the transplanted kidney is functioning adequately in terms of urine production.
C. An elevated white blood cell count of 13,500/mm³ could indicate an infection or inflammation. This finding is relevant in the context of post-transplant care because patients are at increased risk for infections due to immunosuppressive therapy and the surgical procedure. An elevated WBC count could also suggest an acute rejection episode, as rejection can cause inflammation and an immune response.
D. A BUN level of 18 mg/dL is within the normal range but on the higher end. It might suggest some level of kidney impairment, but it is not necessarily indicative of a severe complication on its own.
Correct Answer is D
Explanation
A. While vitamin A can interact with some medications, it does not have a significant effect on verteporfin.
B. Verteporfin does not typically affect blood sugar levels.
C. Verteporfin is usually administered intravenously, so it is not taken orally.
D. Verteporfin is a photosensitizing agent used in photodynamic therapy for age-related macular degeneration. After treatment with verteporfin, the client should avoid sunlight and other intense light for several days to prevent a severe sunburn-like reaction. This is because verteporfin makes the skin and eyes more sensitive to light.
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