A client with a seizure disorder is seen at the clinic for a follow-up visit and a prescription renewal for phenytoin. Which assessment finding warrants immediate intervention by the nurse?

Blood pressure 100/78 mm Hg.

Double vision.

Puffy, bleeding gums.

Chronic insomnia.

Answer and Explanation

The Correct Answer is B

Choice A reason: This is not an assessment finding that warrants immediate intervention by the nurse. Blood pressure 100/78 mm Hg is within the normal range for an adult, and it does not indicate any adverse effect of phenytoin. The nurse should monitor the blood pressure for any changes, but it is not a priority.

Choice B reason: This is an assessment finding that warrants immediate intervention by the nurse. Double vision, or diplopia, is a sign of phenytoin toxicity, which can occur due to overdose, drug interactions, or impaired metabolism. Double vision can impair the client's vision, balance, and coordination, and increase the risk of falls and injuries. The nurse should stop the phenytoin infusion, if applicable, and notify the healthcare provider. The nurse should also check the serum phenytoin level and other vital signs, and prepare to administer an antidote, such as fosphenytoin, if indicated.

Choice C reason: This is not an assessment finding that warrants immediate intervention by the nurse. Puffy, bleeding gums are a common side effect of phenytoin, which can cause gingival hyperplasia, or overgrowth of the gum tissue. Puffy, bleeding gums are not life-threatening, but they can affect the client's oral hygiene and appearance. The nurse should instruct the client to brush and floss the teeth regularly, and to visit a dentist for dental care.

Choice D reason: This is not an assessment finding that warrants immediate intervention by the nurse. Chronic insomnia is not a common or serious side effect of phenytoin, which is an anticonvulsant that can have sedative effects. Chronic insomnia may be caused by other factors, such as stress, pain, or caffeine intake. The nurse should assess the client's sleep pattern and quality, and provide education and counseling on sleep hygiene and relaxation techniques.

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Correct Answer is D

Explanation

Choice A reason: This is not a correct instruction for the nurse to provide to the client. Stopping the oral contraceptive immediately is not necessary, as it may cause irregular bleeding, hormonal imbalance, or unwanted pregnancy. The client should continue taking the oral contraceptive as prescribed, but use an additional form of contraception, such as condoms or spermicides, while taking erythromycin.

Choice B reason: This is not a correct instruction for the nurse to provide to the client. Avoiding prolonged exposure to direct sunlight is not related to the interaction between oral contraceptive and erythromycin. This instruction may be relevant for other antibiotics, such as tetracyclines or sulfonamides, that can cause photosensitivity and increase the risk of sunburn. The client should protect the skin from sun exposure as part of general health promotion, but it is not specific to erythromycin therapy.

Choice C reason: This is not a correct instruction for the nurse to provide to the client. Taking the medications at least 12 hours apart is not sufficient to prevent the interaction between oral contraceptive and erythromycin. Erythromycin is a macrolide antibiotic that can reduce the effectiveness of oral contraceptive by increasing its metabolism and clearance. The client should take the medications as prescribed, but use an additional form of contraception, such as condoms or spermicides, while taking erythromycin.

Choice D reason: This is the correct instruction for the nurse to provide to the client. Using an additional form of contraception is the best way to prevent pregnancy while taking erythromycin and oral contraceptive. Erythromycin can decrease the efficacy of oral contraceptive by increasing its metabolism and clearance. The client should use a barrier method or a spermicide, in addition to the oral contraceptive, while taking erythromycin and for at least one week after finishing the antibiotic course.

A. Ginkgo biloba use should be limited and not taken during pregnancy. B. Aspirin and non-steroidal anti-inflammatory drugs interact with ginkgo. C. Nausea and diarrhea can occur when using this supplement. D. Anxiety and headaches increase with the use of ginkgo biloba.

Correct Answer is B

Explanation

Choice A reason: Ginkgo biloba use should be limited and not taken during pregnancy is a true statement, but not the most important information for the nurse to include in the teaching plan. Ginkgo biloba may have adverse effects on the fetus, such as bleeding, seizures, or malformations. However, this information is only relevant if the client is pregnant or planning to become pregnant. The nurse should assess the client's reproductive status and advise her accordingly.

Choice B reason: Aspirin and non-steroidal anti-inflammatory drugs interact with ginkgo is the most important information for the nurse to include in the teaching plan. Ginkgo biloba has antiplatelet and anticoagulant properties, which means it can prevent blood clots from forming. However, this also increases the risk of bleeding, especially when combined with other drugs that affect blood clotting, such as aspirin and non-steroidal anti-inflammatory drugs (NSAIDs). The nurse should instruct the client to avoid taking these drugs with ginkgo biloba and inform the healthcare provider of all the medications and supplements she is using.

Choice C reason: Nausea and diarrhea can occur when using this supplement is a possible side effect of ginkgo biloba, but not the most important information for the nurse to include in the teaching plan. Nausea and diarrhea are usually mild and transient, and can be reduced by taking ginkgo biloba with food or water. The nurse should inform the client of this possibility and advise her to report any severe or persistent symptoms to the healthcare provider.

Choice D reason: Anxiety and headaches increase with the use of ginkgo biloba is a false statement, and not the information for the nurse to include in the teaching plan. Ginkgo biloba may actually have beneficial effects on anxiety and headaches, as it can improve blood circulation and oxygen delivery to the brain. The nurse should not discourage the client from using ginkgo biloba for these reasons, unless there is a contraindication or an interaction with other drugs.

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A client with a seizure disorder is seen at the clinic for a follow-up visit and a prescription renewal for phenytoin. Which assessment finding warrants immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is taking an oral contraceptive receives a new prescription for erythromycin. Which instruction should the nurse provide to the client?

Correct Answer is D

Explanation

A female client with multiple sclerosis reports having less fatigue and improved memory since she began using the herbal supplement, ginkgo biloba. Which information is most important for the nurse to include in the teaching plan for this client?

Correct Answer is B

Explanation

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