The client was admitted to the medical floor. Upon arrival, the client was assessed: He is difficult to arouse but follows commands. He has a peripheral IV which is infusing normal saline at 145 mL/hr. No redness or edema at the site. Breath sounds are clear and equal bilaterally. He appears pink and well-perfused.
The client had a tonic-clonic seizure that lasted for 3 minutes and 5 seconds. The client became apneic during the seizure and the oxygen saturation dropped to 48%. The client was manually ventilated at 100% oxygen and padding was placed around the vent for safety. After the seizure, the client was turned to his left for recovery.
The physician comes to the bedside following the seizure and prescribes phenytoin. The PN administers the phenytoin as prescribed.
What are the possible toxic effects of phenytoin that the PN should closely monitor the client for after administration?
Select all that apply
Ataxia
Drowsiness
Altered blood coagulation
Anxiety
Aphasia
Vertigo
Visual disturbances
Vomiting
Correct Answer : A,B,C,F,G
Ataxia: Phenytoin can cause problems with coordination and balance, leading to ataxia. The PN should monitor the client for unsteady gait or difficulty with movements.
Drowsiness: Phenytoin can cause drowsiness or sedation. The PN should observe the client for excessive sleepiness or difficulty staying awake.
Altered blood coagulation: Phenytoin can affect blood clotting factors, potentially leading to altered blood coagulation. The PN should assess the client for any signs of bleeding or bruising.
Vertigo: Phenytoin can cause dizziness or vertigo, which is a spinning sensation. The PN should be alert for complaints of dizziness or any difficulty with balance.
Visual disturbances: Phenytoin can cause visual disturbances, such as blurred vision or double vision. The PN should monitor the client's vision and report any changes.
The following options are incorrect regarding the toxic effects of phenytoin:
- Anxiety: Anxiety is not a recognized toxic effect of phenytoin. However, it is important to assess the client for any signs of anxiety or emotional changes.
- Aphasia: Aphasia refers to a language impairment and is not typically associated with the toxic effects of phenytoin.
- Vomiting: While phenytoin can cause gastrointestinal side effects, such as nausea and vomiting, it is not directly related to its toxic effects. However, the PN should still monitor the client for any signs of nausea or vomiting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A callus is a normal response of the body during bone healing, where new bone tissue forms around the fracture site to provide stability and support. It helps in the process of bridging the fracture and promoting healing.
The PN can provide reassurance to the client by explaining that the presence of a callus indicates that the bone is healing and progressing toward recovery. It is important to educate the client about the expected timeline for bone healing and the need for continued follow-up with the healthcare provider.
Incorrect:
A. Prepare to assist in applying a new cast to reduce pressure points: This choice assumes that the client's concern is related to discomfort or pressure points caused by the current cast.
However, the client's concern is about the formation of a callus, which is a normal part of bone healing. There is no indication that a new cast is necessary at this point.
B. Report the client's concern to the healthcare provider: While it's important to address client concerns and communicate any changes in their condition to the healthcare provider, in this case, the formation of a callus is an expected part of the bone healing process. It is not necessary to report this concern to the healthcare provider as it is a normal occurrence.
D. Teach the client strategies to prevent further calluses: The formation of a callus in this context is a natural response of the body to promote bone healing. It is not necessary to teach the client strategies to prevent further calluses, as callus formation is a temporary and beneficial part of the healing process.
Correct Answer is D
Explanation
Choice A reason:
Instructing the UAP in the correct removal of contaminated gloves focuses only on one aspect of the PPE removal process. While it is important to remove gloves correctly to prevent contamination, this choice does not address the comprehensive handling of all isolation attire. Proper PPE removal involves multiple steps, including the removal of gowns, masks, and gloves in a specific order to minimize the risk of contamination.
Choice B reason:
Reminding the UAP to remove the gown before removing gloves addresses part of the PPE removal process but not the entire procedure. The correct sequence for removing PPE is crucial to prevent self-contamination. However, this choice does not ensure that all steps are followed correctly. The PN needs to confirm that the UAP understands and correctly performs the entire process, not just one step.
Choice C reason:
Advising the UAP to remove the mask after exiting the room is incorrect because masks should be removed before leaving the isolation room to prevent contamination of the environment outside the isolation area. Droplet precautions require that masks be removed inside the room to contain any infectious agents within the isolation area. This choice could lead to the spread of infection if not followed correctly.
Choice D reason:
Confirming that the UAP has correctly handled the isolation attire ensures that all steps in the PPE removal process are followed correctly. This comprehensive approach helps maintain infection control standards and prevents the spread of infectious agents. By verifying that the UAP has correctly removed and disposed of all PPE, the PN ensures that the UAP adheres to proper protocols, thereby protecting both the healthcare workers and other clients.
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