A nurse is reinforcing teaching a client who has a new prescription for phenytoin. The nurse should instruct the client to monitor and report which of the following adverse effects of this medication?
Diarrhea
Wrist pain
Skin rash
Metallic taste
The Correct Answer is C
A. Diarrhea:
Diarrhea is not a common side effect of phenytoin. While gastrointestinal disturbances such as nausea, vomiting, and constipation may occur, diarrhea is less common. Therefore, it is not a primary adverse effect that the nurse should instruct the client to monitor and report.
B. Wrist pain:
Wrist pain is not a common side effect of phenytoin. Side effects related to musculoskeletal issues such as joint pain, muscle weakness, or muscle twitching can occur, but wrist pain specifically is not commonly associated with phenytoin use. Therefore, it is not a primary adverse effect that the nurse should instruct the client to monitor and report.
C. Skin rash:
Skin rash is a potential adverse effect of phenytoin that should be monitored and reported. Phenytoin can cause various skin reactions, including a mild rash or more severe reactions such as Stevens-Johnson syndrome or toxic epidermal necrolysis. Therefore, the nurse should instruct the client to promptly report any signs of skin rash or other skin changes.
D. Metallic taste:
Metallic taste is a common side effect of phenytoin. While it is not usually a serious adverse effect, it can be bothersome for some individuals. Therefore, the nurse should instruct the client to monitor for this side effect and report it if it occurs persistently or becomes bothersome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Pupil response:
Pupil response refers to the reaction of the pupils to light stimulus. The pupils should normally constrict when exposed to bright light and dilate in dim light. Changes in pupil size or reactivity can indicate alterations in neurological function. For example, unequal or non-reactive pupils (anisocoria or fixed pupils) can be indicative of dysfunction in the cranial nerves or brainstem. However, while pupil response is an important aspect of neurological assessment, it may not always be the earliest indicator of cerebral status changes.
B. Deep tendon reflexes:
Deep tendon reflexes are involuntary muscle contractions in response to stretching of a muscle tendon. These reflexes are assessed by tapping the tendon with a reflex hammer, eliciting a rapid and brief muscle contraction. Changes in deep tendon reflexes can provide information about the integrity of the peripheral nervous system and spinal cord. However, alterations in deep tendon reflexes may occur secondary to changes in cerebral function and are typically assessed along with other neurological signs.
C. Muscle strength:
Muscle strength refers to the force generated by muscles during voluntary movement. It is typically assessed by asking the client to perform specific movements against resistance or by testing the strength of individual muscle groups using standardized scales (e.g., Medical Research Council scale). Changes in muscle strength can occur due to neurological or musculoskeletal conditions. While weakness or paralysis can result from lesions affecting the upper motor neurons (e.g., strokes or spinal cord injuries), alterations in muscle strength may not always be the earliest indicator of cerebral status changes.
D. Level of consciousness:
The level of consciousness refers to the degree of awareness and alertness exhibited by the client. It is assessed by evaluating the client's responsiveness, orientation, and ability to follow commands. Changes in the level of consciousness, such as confusion, lethargy, stupor, or coma, can indicate alterations in cerebral function and are often the earliest indicators of neurological dysfunction. Assessing the level of consciousness is a critical component of neurological examination and helps guide further assessment and management of clients with suspected brain tumors or other neurological conditions.
Correct Answer is C
Explanation
A. Hyperglycemia:
Hyperglycemia refers to high blood sugar levels. While certain medications can affect glucose metabolism and potentially lead to hyperglycemia as a side effect, this is not typically associated with hydantoin therapy for seizure disorder. Therefore, it is less likely for the patient to experience hyperglycemia as a direct result of taking hydantoin medication.
B. Hunger:
Hunger is not a common side effect of hydantoin therapy for seizure disorder. While some medications may affect appetite or cause changes in eating habits, hunger is not a typical side effect of hydantoin medications such as phenytoin.
C. Hypoglycemia:
Hypoglycemia refers to low blood sugar levels, which can lead to symptoms such as confusion, dizziness, sweating, and weakness. Hydantoin medications, particularly phenytoin, can affect glucose metabolism and increase the risk of hypoglycemia, especially in patients who already have diabetes or are prone to low blood sugar. Therefore, it is important for patients taking hydantoin therapy to monitor their blood sugar levels regularly and be aware of the signs and symptoms of hypoglycemia.
D. Pupil dilation:
Pupil dilation, or mydriasis, is not a common side effect of hydantoin therapy for seizure disorder. While certain medications may affect pupil size, this is not typically associated with hydantoin medications such as phenytoin.
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