Exhibits

Select the 2 actions the nurse should prepare to take for the client.

A. Completing an incident report is required for tracking falls and improving safety measures, but it is not the first priority. The nurse must first assess the client to determine if immediate medical intervention is needed. Delay in assessment could lead to unrecognized injuries or complications. Incident reports are also not part of the medical record and should be completed after client care. Ensuring client stability always takes precedence over documentation.
B. Measuring vital signs is the priority because it helps identify any immediate complications from the fall, such as hypotension, pain, or neurological impairment. A sudden drop in blood pressure could indicate shock, while tachycardia may suggest distress or injury. Checking for changes in mental status, pain levels, and potential fractures ensures timely intervention. If abnormalities are found, further evaluation or treatment can be initiated promptly. Early assessment prevents worsening conditions and guides further actions.
C. Documenting the fall in the client's medical record is necessary for continuity of care but should be done after assessing and stabilizing the client. Medical documentation includes details about the fall, findings from the assessment, and any interventions provided. However, delaying assessment to document first could result in missed critical signs of injury. Proper documentation supports quality care but is secondary to ensuring the client’s immediate well-being. The nurse should prioritize physical assessment before recording the incident.
D. Notifying the provider is important, especially if the client has sustained injuries, is in pain, or has abnormal vital signs. However, calling the provider before performing an assessment can lead to incomplete or inaccurate reporting. The provider will need specific details about the client's condition, including neurological status, hemodynamics, and any visible injuries. Conducting an assessment first ensures that the provider receives the most relevant and useful information. Immediate assessment allows for timely intervention and prevents unnecessary delays in care.

A. "You might experience swollen gums while taking this medication." Phenytoin is known to cause gingival hyperplasia, which is swelling and overgrowth of the gums. This is a common side effect, and clients should be informed about it so they can maintain good oral hygiene and seek dental care if necessary.
B. "You can skip a dose of this medication if you are nauseated." Skipping doses is not advised. Phenytoin should be taken consistently, and skipping doses can lead to decreased seizure control. If nausea occurs, the client should contact their healthcare provider for guidance.
C. "You can safely take this medication if you become pregnant." Phenytoin is classified as a Category D medication, indicating evidence of risk to the fetus. Women of childbearing age should discuss effective contraception and consult their healthcare provider regarding the risks associated with taking phenytoin during pregnancy.
D. "You should expect to have blood work every 6 months while taking this medication." Regular monitoring of serum levels is necessary, typically every 1-3 months, especially after dosage changes. Monitoring ensures therapeutic levels and prevents toxicity, so stating that blood work is only required every 6 months may be insufficient.