A client with myasthenia gravis is given a Tensilon test. Forty minutes after the test, the client develops severe weakness and ptosis. The nurse should be prepared to:
A)Administer atropine
B)Administer pyridostigmine
C)Check for constricted pupils
D)Intubate the client

Question

Quizplus · Accepted Answer

Developing severe weakness within 1 hour of the administration of Tensilon indicates a cholinergic crisis, or overdose of anticholinesterase drugs. The antidote for cholinergic crisis is atropine. Choice B is incorrect because it would be inappropriate to administer an anticholinesterase drug, such as pyridostigmine, to a client in cholinergic crisis. Choice C is incorrect because checking for constricted pupils does not provide useful information. Pupil constriction does not occur during a cholinergic crisis. Choice D is incorrect because intubation is not the first action. Atropine should be used first to counteract the toxic effects of the anticholinesterase drug.

A Client with Myasthenia Gravis Is Given a Tensilon Test