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 B
Explanation
A. Using a thermometer to check the temperature of bath water is a safe practice that helps prevent burns, which is important for clients with PVD who may have reduced sensation.
B. Wearing stockings with elastic tops can restrict blood flow and is generally not recommended for clients with PVD; clients should use non-restrictive stockings instead.
C. Not going barefoot is a good practice to prevent injuries and ulcers, which are risks for clients with PVD.
D. Avoiding crossing the legs is advisable as it helps maintain adequate blood flow and reduces the risk of circulation problems.
Correct Answer is D
Explanation
A. Black cohosh is typically used for menopausal symptoms and does not have a known effect on walking distance in peripheral arterial disease.
B. Echinacea is primarily used to boost the immune system and treat colds, not for vascular conditions.
C. Saw palmetto is commonly used for benign prostatic hyperplasia (BPH) and does not have evidence supporting its use for peripheral arterial disease.
D. Ginkgo biloba has been shown to improve blood flow and may help increase pain-free walking distance in clients with peripheral arterial disease by enhancing peripheral circulation.