A patient has been taking phenytoin (Dilantin) for 2 years. Which action should the nurse take when evaluating possible adverse effects of the medication?

Auscultate the bowel sounds.

Inspect the oral mucosa

Check pupil reaction to light.

Listen to the lung sounds.

Answer and Explanation

The Correct Answer is B

A. Auscultate the bowel sounds: While gastrointestinal side effects such as nausea or
constipation can occur with phenytoin, auscultating bowel sounds is not a specific assessment related to its adverse effects.

B. Inspect the oral mucosa: Phenytoin is associated with gingival hyperplasia, a condition characterized by overgrowth of gum tissue. Therefore, inspecting the oral mucosa for signs of gum enlargement or other oral changes is important for evaluating adverse effects of phenytoin.

C. Check pupil reaction to light: Phenytoin does not typically affect pupil reaction to light. This assessment is more relevant for medications that act on the central nervous system or conditions affecting cranial nerve function.

D. Listen to the lung sounds: Phenytoin is not typically associated with respiratory side effects. Assessing lung sounds may be relevant in certain clinical situations, but it is not a specific assessment related to phenytoin adverse effects.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Administer naproxen: While pain management is important, naproxen may not effectively resolve the headache associated with post-lumbar puncture headache (PLPH), which is often caused by cerebrospinal fluid leakage.

B. Elevate the head of the bed to 30°: While elevating the head of the bed may provide some relief, it is not typically sufficient to resolve PLPH, which often requires more definitive interventions.

C. Check BP and call for a blood patch: PLPH is commonly treated with a blood patch, which involves injecting the patient's own blood into the epidural space to seal the puncture site and restore normal cerebrospinal fluid pressure. Checking blood pressure is important to assess for hypotension, and calling for a blood patch is the most appropriate action to address the underlying cause of the headache.

D. Darken the client's room and close the door: While creating a quiet and dim environment may help alleviate symptoms of headache, it does not address the underlying cause of PLPH and is not the most appropriate intervention in this situation.

A. Therapeutic effects of medications may not be seen for 2-3 weeks B. Physical dependency may result from extended use of medications C. Urine may turn pink to brown but is not harmful D. Take medication even if there is no seizure activity

Correct Answer is D

Explanation

A. Therapeutic effects of medications may not be seen for 2-3 weeks: While it is important for the client to understand the timeline for therapeutic effects, ensuring medication adherence, especially during the initial period when therapeutic effects are not yet apparent, is of higher priority.
B. Physical dependency may result from extended use of medications: While the potential for physical dependency is an important consideration, ensuring medication compliance and adherence to the prescribed regimen, particularly in the context of managing seizures, takes precedence.
C. Urine may turn pink to brown but is not harmful: While this information may be included in the education plan to address potential side effects of antiepileptic medications, it is not the highest priority compared to ensuring the client understands the importance of taking medication regularly.
D. Take medication even if there is no seizure activity: Ensuring consistent medication adherence is crucial in managing seizure disorders to maintain therapeutic blood levels of antiepileptic medications and reduce the risk of breakthrough seizures. Missing doses can increase the risk of seizure recurrence.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A patient has been taking phenytoin (Dilantin) for 2 years. Which action should the nurse take when evaluating possible adverse effects of the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports a throbbing headache and hypotension after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?

Correct Answer is C

Explanation

Which of the following should be the highest priority of education plan for a client being treated with medication therapy for a generalized seizure disorder?

Correct Answer is D

Explanation

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take?

A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action should the nurse include in the plan of care?

Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider?

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.)

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following medication would the nurse anticipate to administer?

A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room? (Select all that apply.)