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 the action that the nurse should implement. Determining Glasgow Coma Scale score is a method of assessing the level of consciousness and neurological function of the client, but it is not a priority intervention in this situation. The client's respiratory rate and oxygen saturation are more critical indicators of the client's condition and the need for immediate action. The nurse should assess the Glasgow Coma Scale score as part of the ongoing evaluation, but it is not the first action.

Choice B reason: This is not the action that the nurse should implement. Initiating cardiopulmonary resuscitation (CPR) is a lifesaving procedure that is performed when the client has no pulse and no breathing, but it is not indicated in this situation. The client has a respiratory rate of 4 breaths/minute, which is very low, but not absent. The client also has an oxygen saturation of 75%, which is very low, but not incompatible with life. The nurse should provide oxygen therapy and ventilatory support to the client, but not CPR.

Choice C reason: This is not the action that the nurse should implement. Preparing to assist with chest tube insertion is a procedure that is done to drain air or fluid from the pleural space and restore lung expansion, but it is not relevant in this situation. The client's respiratory depression is caused by the opioid overdose, not by a pneumothorax or a pleural effusion. The nurse should monitor the client's chest x-ray and lung sounds, but not prepare for chest tube insertion.

Choice D reason: This is the action that the nurse should implement. Administering a second dose of naloxone is the most appropriate and effective intervention in this situation. Naloxone is an opioid antagonist that reverses the effects of opioids, such as respiratory depression, sedation, and hypotension. However, naloxone has a shorter duration of action than most opioids, and it may require repeated doses to maintain the reversal. The nurse should administer a second dose of naloxone if the client's respiratory rate and oxygen saturation do not improve or worsen after the first dose. The nurse should also monitor the client for signs of opioid withdrawal, such as agitation, nausea, or pain.

A. At the onset of signs of diabetic ketoacidosis. B. Before meals to prevent hyperglycemia. C. When unable to eat during sick days. D. When signs of severe hypoglycemia occur.

Correct Answer is D

Explanation

Choice A reason: Diabetic ketoacidosis is a complication of diabetes that occurs when the body produces high levels of ketones due to lack of insulin. Glucagon is not indicated for this condition, as it would increase the blood glucose level even more. The nurse should instruct the client and family to monitor the blood glucose and ketone levels, administer insulin as prescribed, and seek medical attention if the condition worsens.

Choice B reason: Glucagon is not used to prevent hyperglycemia, which is a high blood glucose level. Glucagon is a hormone that raises the blood glucose level by stimulating the breakdown of glycogen in the liver. The nurse should instruct the client and family to prevent hyperglycemia by following a balanced diet, taking insulin as prescribed, and exercising regularly.

Choice C reason: Glucagon is not used when the client is unable to eat during sick days, unless the client has signs of hypoglycemia, which is a low blood glucose level. Glucagon is used as a last resort when the client is unconscious or unable to swallow. The nurse should instruct the client and family to follow the sick day rules, which include monitoring the blood glucose and urine ketone levels, taking insulin as prescribed, drinking fluids, and eating small amounts of carbohydrates.

Choice D reason: Glucagon is used when the client has signs of severe hypoglycemia, such as confusion, seizures, or loss of consciousness. Glucagon is injected subcutaneously or intramuscularly by a family member or a caregiver to raise the blood glucose level quickly. The nurse should instruct the client and family to recognize the signs of hypoglycemia, treat mild to moderate hypoglycemia with oral glucose, and call 911 after administering glucagon.

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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

The nurse administers naloxone to a client with opioid-induced respiratory depression. One hour later, nursing assessment reveals that the client has a respiratory rate of 4 breaths/minute, oxygen saturation of 75%, and is unable to be aroused. Which action should the nurse implement?

Correct Answer is D

Explanation

A glucagon emergency kit is prescribed for a client with type 1 diabetes mellitus to be used at home. When should the nurse instruct the client and family that glucagon needs to be administered?

Correct Answer is D

Explanation

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