A nurse is caring for a client immediately following a hemodialysis treatment. For which of the following manifestations will the nurse administer a PRN dose of phenytoin?

 

Choice A reason: A distended bladder can cause low back pain due to the pressure and stretching of the bladder wall, which is often related to a urinary disorder such as urinary retention or obstruction.

Choice B reason: A stress fracture is less likely to be the cause of low back pain associated with an inability to void and a distended bladder.

Choice C reason: Nerve root pain typically presents with radiating pain down the leg rather than low back pain associated with urinary symptoms.

Choice D reason: Renal cancer could potentially cause low back pain, but it would not typically cause an inability to void or a distended bladder without other significant symptoms.

The correct answer is Choice A

Choice A rationale: Headache and restlessness can be signs of a seizure or neurological disturbance, which phenytoin is used to treat. Phenytoin is an anticonvulsant medication that helps control seizures by stabilizing neuronal membranes and reducing excitability.

Choice B rationale: Decreased blood pressure and rapid pulse are not indications for phenytoin administration. These symptoms may suggest hypotension or cardiovascular issues, which require different interventions such as fluid resuscitation or vasopressors.

Choice C rationale: Muscle cramps and chest heaviness are not treated with phenytoin. These symptoms could indicate electrolyte imbalances or cardiac issues, which need specific treatments like electrolyte replacement or cardiac monitoring.

Choice D rationale: Pain and tingling at the access site are not indications for phenytoin administration. These symptoms may suggest local irritation or infection at the dialysis access site, requiring appropriate wound care or antibiotics.