A few days after a Cerebral Vascular Accident, the patient's family asks the nurse if tissue plasminogen activator (tPA) is a drug therapy option now. The nurse's response based on the knowledge that this drug must be used within:

A. Check the client for a fecal impaction.

This intervention is important for managing autonomic dysreflexia because a fecal impaction can trigger autonomic dysreflexia by causing rectal distention. However, it is not the first action the nurse should take. Promptly addressing the immediate cause of autonomic dysreflexia is crucial to prevent complications.

B. Ensure the room temperature is warm.

This intervention is important for maintaining the client's comfort and preventing temperature-related complications. However, it is not the first action the nurse should take when suspecting autonomic dysreflexia. Immediate interventions to address the underlying cause of autonomic dysreflexia are necessary to prevent serious complications such as stroke or seizure.

C. Check the client's bladder for distention.

This is the correct action to take first. Bladder distention is one of the most common triggers of autonomic dysreflexia in individuals with spinal cord injuries. A distended bladder stimulates autonomic reflexes, leading to a sudden increase in blood pressure. Therefore, the nurse should assess the client's bladder for distention and initiate appropriate interventions such as catheterization to relieve urinary retention.

D. Raise the head of the bed.

While elevating the head of the bed can help reduce blood pressure in some situations, it is not the first action the nurse should take when suspecting autonomic dysreflexia. Elevating the head of the bed may exacerbate autonomic dysreflexia by increasing venous return and blood pressure. Therefore, addressing the underlying cause of autonomic dysreflexia, such as bladder distention, takes priority.

A. "I will notify my provider before taking any other medications."

This statement demonstrates understanding of the importance of consulting the provider before taking any other medications. It is correct because phenytoin may interact with other drugs, so notifying the provider is essential to avoid potential interactions.

B. "I have made an appointment to see my dentist next week."

This statement indicates that the client understands the importance of dental care while taking phenytoin. Phenytoin can cause gum overgrowth (gingival hyperplasia), so regular dental check-ups are recommended to monitor oral health. This statement is correct.

C. "I will take this medication with meals."

This statement suggests that the client plans to take phenytoin with meals. However, phenytoin should generally be taken on an empty stomach to enhance absorption, unless gastrointestinal upset occurs. Therefore, this statement indicates a need for further teaching.

D. "I'll be glad when my seizures stop so I can quit taking this medicine."

This statement reflects a misconception about the management of epilepsy. Phenytoin is typically used as a long-term treatment to prevent seizures, not as a short-term solution to stop seizures. Therefore, this statement indicates a need for further education about the chronic nature of epilepsy and the need for ongoing medication adherence.

E. “I’ll take this medication before meals.”

This statement correctly indicates the timing of phenytoin administration before meals. Taking phenytoin before meals helps enhance absorption and minimize the risk of gastrointestinal side effects. Therefore, this statement is correct.