A nurse is assessing a client after administering phenytoin IV bolus for a seizure. Which of the following findings should the nurse identify as an adverse effect of this medication?
Bradycardia.
Red man syndrome.
Hypotension.
Hypoglycemia.
The Correct Answer is C
Phenytoin is an anticonvulsant medication that can cause hypotension as an adverse effect when administered intravenously. The nurse should monitor the client’s blood pressure and heart rate during and after the infusion.
Choice A is wrong because phenytoin does not cause bradycardia. Bradycardia is a slow heart rate that can result from beta blockers, calcium channel blockers, or digoxin toxicity.
Choice B is wrong because red man syndrome is an adverse reaction to vancomycin, not phenytoin.
Red man syndrome is characterized by flushing, itching, and rash on the face, neck, and upper torso.
Choice D is wrong because phenytoin does not cause hypoglycemia. Hypoglycemia is a low blood glucose level that can result from insulin overdose, excessive exercise, or inadequate food intake.
Normal ranges for blood pressure are 90/60 mm Hg to 120/80 mm Hg. Normal ranges for heart rate are 60 to 100 beats per minute. Normal ranges for blood glucose are 70 to 110 mg/dL.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
a.While weight changes can be concerning, they are not typically life-threatening and can occur as a common side effect of antidepressants, including citalopram. Monitoring is important, but it does not require immediate reporting.
b.This is the priority to report because confusion can indicate a serious reaction to the medication, such as serotonin syndrome, especially if it occurs in conjunction with other symptoms like agitation, hallucinations, or rapid heart rate. Confusion can also signal worsening mental status, which is critical for someone with major depression.
c.This refers to teeth grinding, which can occur with certain antidepressants. While it should be monitored and possibly addressed with interventions, it is generally not an immediate concern compared to confusion.
d.Sleep disturbances can be a side effect of citalopram and may need adjustment of treatment or recommendations for sleep hygiene, but they are not as urgent as confusion.
Correct Answer is A
Explanation
The FACES pain scale is a self-report tool that uses six facial expressions to indicate different levels of pain. It is suitable for children aged 3 to 13 years who can match their pain to a face. The nurse should use this scale to assess the pain of a 4-year-old child following an orthopaedic procedure.
Choice B. Word-graphic is wrong because it is a pain scale that uses words and pictures to describe pain intensity.
It is suitable for children aged 8 to 17 years who can read and understand words.
Choice C. Numeric is wrong because it is a pain scale that uses numbers from 0 to 10 to rate pain intensity. It is suitable for children aged 5 years and older who can understand numbers and concepts of more or less.
Choice D. CRIES is wrong because it is a pain scale that uses five behavioural indicators (crying, requiring increased oxygen, increased vital signs, expression, and sleeplessness) to measure pain in neonates.
It is suitable for infants aged 0 to 6 months who cannot communicate verbally.
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