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 C
Explanation
A. Instruct the client to perform controlled coughing and deep breathing.
This intervention is not appropriate for a client with increased intracranial pressure. Controlled coughing and deep breathing can increase intrathoracic pressure, which can in turn increase intracranial pressure. Therefore, this intervention should be avoided in clients with increased ICP.
B. Provide a brightly lit environment.
This intervention is not appropriate for a client with increased intracranial pressure. Bright lights can stimulate the reticular activating system and increase arousal, potentially exacerbating cerebral metabolic demand and intracranial pressure. Therefore, it is recommended to provide a calm, quiet environment with subdued lighting for clients with increased ICP.
C. Elevate the head of the bed 30°.
This intervention is correct. Elevating the head of the bed to 30 degrees promotes venous drainage from the head and reduces intracranial pressure. It helps prevent venous congestion in the brain and improves cerebral perfusion. This position is commonly used in clients with increased intracranial pressure to optimize cerebral blood flow.
D. Encourage a minimum intake of 2,000 mL/day of clear fluids.
This intervention is not appropriate for a client with increased intracranial pressure. While maintaining hydration is important for overall health, excessive fluid intake can increase intracranial pressure by increasing cerebral blood volume and cerebrospinal fluid production. Therefore, fluid intake should be carefully monitored and adjusted based on the client's condition and fluid balance.
Correct Answer is A
Explanation
A. 4 hours:
This option indicates that tissue plasminogen activator (tPA) must be administered within 4 hours of the onset of stroke symptoms to be considered as a drug therapy option. tPA is a thrombolytic medication used to dissolve blood clots in ischemic stroke, and its effectiveness is highest when administered promptly after the onset of symptoms.
B. 1 hour:
Administering tPA within 1 hour of stroke onset would be extremely challenging and impractical. It typically takes time for patients to recognize stroke symptoms, seek medical attention, and undergo diagnostic evaluations before tPA administration. While time is of the essence in stroke treatment, 1 hour is too short of a timeframe for most patients to receive tPA.
C. 24 hours:
Administering tPA beyond 4.5 hours of stroke onset is generally contraindicated due to the increased risk of complications, including hemorrhagic transformation of the stroke. While there may be some extended time windows considered for certain patients under specific circumstances, such as those meeting eligibility criteria for extended thrombolytic therapy, 24 hours is outside the standard timeframe for tPA administration.
D. 8 hours:
While tPA administration within 8 hours of stroke onset may be feasible for some patients, it is beyond the standard recommended time window for optimal effectiveness. As mentioned earlier, tPA is most effective when administered within the first 3 to 4.5 hours after the onset of symptoms, with earlier administration associated with better outcomes.
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