A nurse is caring for a client who is scheduled for a Tensilon challenge test to check for myasthenia gravis. Which of the following findings should the nurse identify as a positive result?
Muscle strength becomes temporarily stronger.
A "pill-rolling" tremor appears.
Electrical charge in the muscle increases in intensity.
Muscle strength shows no change.
The Correct Answer is A
A. A positive result in a Tensilon test is indicated by a temporary improvement in muscle strength following the administration of edrophonium (Tensilon), confirming the diagnosis of myasthenia gravis.
B. A "pill-rolling" tremor is associated with Parkinson's disease, not myasthenia gravis, and is not relevant to this test.
C. While muscle electrical activity can be assessed in other tests, the Tensilon test specifically evaluates muscle strength changes, not electrical charge intensity.
D. No change in muscle strength would suggest a negative result for myasthenia gravis, indicating that the test did not confirm the diagnosis.
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Correct Answer is C
Explanation
A. Monitoring electrolyte levels is important but is not as immediate as ensuring airway patency.
B. Performing passive range of motion is beneficial for mobility but does not address the immediate needs of an unconscious patient.
C. Suctioning saliva from the client's mouth is the highest priority intervention, as maintaining airway clearance is critical to prevent aspiration and ensure adequate ventilation.
D. Recording intake and output is necessary for overall assessment but is not as urgent as managing the airway.
Correct Answer is D
Explanation
A. Gelatin allergies are not directly related to cardiac catheterization procedures, as iodine-based contrast media is typically used.
B. A yeast allergy is unrelated to the contrast dye or materials used in the procedure.
C. Egg allergies may be relevant to some medications or vaccines, but they are not typically a concern in cardiac catheterization.
D. Shellfish allergies are important because clients with shellfish allergies may also react to iodine-based contrast dyes commonly used in cardiac catheterization procedures.