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 B
Explanation
Immune thrombocytopenic purpura (ITP) is a condition characterized by low platelet levels in the blood, which can lead to an increased risk of bleeding and bruising. Patients with ITP are at risk of spontaneous bleeding, and any injury can be potentially serious.
Ensuring the client has minimal clutter in the room is essential to reduce the risk of accidental falls and injuries. Falls and bumps can lead to bruising or bleeding, which can be particularly problematic in individuals with low platelet counts.
Incorrect:
A. Assessing the client for nerve pain or paralysis is important in the overall care of the patient, but it may not directly address the prevention of injury in this situation.
C. Evaluating the client's neurological status after exercising is also essential for assessing their overall health and well-being but may not directly prevent injury.
D. Monitoring the client's blood cell laboratory values, including platelet levels, is crucial for managing ITP, adjusting treatment if needed, and ensuring the client's condition remains stable. However, while important, this action is not directly related to preventing immediate injury in the care facility.
Correct Answer is A
Explanation
The appropriate action for the practical nurse (PN) in this situation would be to ask the client if he is currently hearing voices. This step is important to assess the client's current state and gather information about his experiences. By directly asking the client about hearing voices, the PN can gain insight into the client's symptoms and determine if there is a need for further intervention or support.
B. Having the unlicensed assistive personnel (UAP) escort the client to his room may not be necessary at this point, as the client may simply be engaging in self-talk or may prefer some time alone. However, if the client's behavior becomes disruptive, agitated, or poses a safety risk, involving the UAP or taking other appropriate measures may be warranted.
C. Recording the event is important for documentation purposes, but it should not be the only action taken. It is crucial to actively assess the client's well-being and address any potential concerns or needs.
D. Administering an as-needed (PRN) dose of haloperidol without further assessment or consulting the healthcare provider would be inappropriate. Medication decisions should be based on a comprehensive evaluation of the client's symptoms and the healthcare provider's recommendations.
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