A nurse is reinforcing teaching with a female client who is taking phenytoin. Which of the following statements should the nurse include in the teaching?
"You can safely take this medication if you become pregnant."
"You can skip a dose of this medication if you are nauseated."
"You should expect to have blood work every 6 months while taking this medication."
"You might experience swollen gums while taking this medication."
The Correct Answer is D
A. Incorrect. Phenytoin is known to be a teratogenic medication, meaning it can cause birth defects. It is important for females of childbearing age to use effective contraception while taking phenytoin and to discuss pregnancy plans with their healthcare provider.
B. Incorrect. Skipping a dose of phenytoin can lead to changes in blood levels of the medication and may result in decreased seizure control. Nausea should be managed with the guidance of the healthcare provider.
C. Incorrect. Phenytoin can require regular monitoring of blood levels, but the frequency of blood work may vary based on the client's individual needs. Blood work is usually done more frequently than every 6 months, especially when starting or adjusting the medication.
D. Correct. Phenytoin can cause gingival hyperplasia, which leads to swollen and overgrown gums. This is a common side effect that clients should be informed about.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. Mentioning the completion of an incident report is appropriate but not sufficient in explaining the incident.
B. Correct. Documenting the client's own statement about the fall is essential for accuracy and clarity in the medical record.
C. Incorrect. While footwear might contribute to falls, it's important to include the client's own account of the fall in the documentation.
D. Incorrect. While noting the absence of visible injuries is relevant, it's more important to document the circumstances leading to the fall.
Correct Answer is A
Explanation
A. Correct. Lightheadedness upon standing, also known as orthostatic hypotension, can be a common side effect of ACE inhibitors. Advising the client to sit down when experiencing lightheadedness will help prevent falls.
B. Incorrect. Discontinuing the medication without consulting a healthcare provider is not appropriate. Lightheadedness can be managed with strategies like changing positions slowly.
C. Incorrect. Restricting fluid intake is not necessary unless advised by a healthcare provider.
Adequate hydration is important, especially with the use of certain medications.
D. Incorrect. While potassium supplements might be prescribed in some cases with ACE inhibitors, the primary concern in this situation is addressing orthostatic hypotension.
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