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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Incorrect. Instructing the client's family about the purpose of mitten restraints requires nursing judgment and explanation. It is beyond the scope of an assistive personnel's role.
B. Correct. Assisting the client with a range of motion exercises of the hands is a task that can be safely delegated to assistive personnel. It is a routine activity and does not require advanced assessment.
C. Incorrect. Evaluating the need for the client to remain in restraints requires nursing assessment and decision-making.
D. Incorrect. Determining the circulation status of the extremities requires nursing assessment skills and clinical judgment. It is not appropriate to delegate this task to assistive personnel.
Correct Answer is D
Explanation
A. Droplet precautions are not indicated for HIV; standard precautions should be followed.
B. Granulocyte colony-stimulating factor is typically used to increase white blood cell production and is not directly related to HIV care.
C. Exchange transfusions are not a routine intervention for infants with HIV.
D. Correct. Monitoring the infant's lymphocyte count is important to assess immune function and response to HIV treatment.
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