The client is suspected of having myasthenia gravis. Edrophonium (Tensilon) 2 mg is administered intravenously to determine the diagnosis. Which of the following indicates that the client has myasthenia gravis?

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Question 1 of 5

The client is suspected of having myasthenia gravis. Edrophonium (Tensilon) 2 mg is administered intravenously to determine the diagnosis. Which of the following indicates that the client has myasthenia gravis?

Correct Answer: D

Rationale: Edrophonium (Tensilon) is a short-acting cholinesterase inhibitor used in the Tensilon test to aid in the diagnosis of myasthenia gravis. In patients with myasthenia gravis, there is a deficiency of acetylcholine at the neuromuscular junction, leading to muscle weakness. By inhibiting the breakdown of acetylcholine, edrophonium temporarily increases the availability of acetylcholine at the neuromuscular junction.

Question 2 of 5

Which of the ff. would the nurse explain to a patient is the main purpose of a hearing aid?

Correct Answer: D

Rationale: The main purpose of a hearing aid is to improve the patient's ability to hear. Hearing aids are devices designed to amplify sound for individuals with hearing loss or difficulty hearing. They do not amplify background noise or musical sounds specifically; instead, they are meant to enhance the overall perception of sounds to help individuals better understand speech and communicate effectively. Moreover, hearing aids do not occlude the ear, but rather are used to transmit sound into the ear canal to make sounds louder and clearer for the wearer.

Question 3 of 5

A client with serum glucose level of 618mg/dl is admitted to the facility. He's awake and oriented, has hot dry skin, and has the following vital signs: temperature of 100.6F (38.1C), heart rate of 116 beats/min, and blood pressure of 108/70mHg. Based on these assessment findings, which nursing diagnosis take highest priority?

Correct Answer: A

Rationale: The client's serum glucose level of 618mg/dl is indicative of severe hyperglycemia, likely due to uncontrolled diabetes mellitus. The client's presentation with hot dry skin, elevated heart rate, and low blood pressure suggests dehydration as a result of osmotic diuresis, which occurs in an attempt to excrete excess glucose. With an elevated heart rate and low blood pressure, it is essential to address the deficient volume to prevent further complications such as hypovolemic shock. Rehydration and fluid replacement are crucial interventions to help restore the client's fluid balance and prevent hemodynamic instability. Addressing the deficient volume related to osmotic diuresis should take the highest priority in this case.

Question 4 of 5

A client has a serum calcium level of 7.2mg/dl. During the physical examination, the nurse expects to assess:

Correct Answer: A

Rationale: A client with a low serum calcium level (hypocalcemia) is at risk for exhibiting Trousseau's sign. Trousseau's sign is a clinical manifestation of hypocalcemia characterized by carpal spasm induced by inflating a blood pressure cuff on the arm above the systolic pressure for a few minutes. This spasm occurs due to the increased neuromuscular irritability caused by low calcium levels. Therefore, a nurse assessing a client with a serum calcium level of 7.2mg/dl should expect to assess Trousseau's sign.

Question 5 of 5

An adult had a total thyroidectomy. Which statement by the client demonstrates to the nurse an adequate understanding of long term care?

Correct Answer: A

Rationale: An adult who had a total thyroidectomy will no longer be able to produce thyroid hormones naturally. Therefore, the client will need to take replacement hormones for the rest of their life to maintain normal bodily functions and prevent complications associated with hypothyroidism. This statement demonstrates an adequate understanding of the long-term care needed after a total thyroidectomy. The other options do not accurately reflect the necessary long-term care for someone who has undergone a total thyroidectomy.

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