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

Choice A: Document the client's loss of memory in the record.

While it's important to document changes in a patient's condition, this should not be the first action. The confusion might be temporary and due to the new environment. It's crucial to first address the patient's immediate needs.

Choice B: Remind the client what day of the week it is.

This is the best action to take. The patient is likely experiencing "relocation stress syndrome," which can cause confusion and disorientation in a new environment. Reminding her of the day can help reorient her and alleviate her confusion.

Choice C: Encourage the client to rest during the day.

While rest is important, it doesn't directly address the patient's confusion about the day of the week. Furthermore, excessive daytime sleep can disrupt the patient's sleep-wake cycle and potentially exacerbate confusion.

Choice D: Notify the family of the change in the client's condition.

While it's important to keep the family informed, this should not be the first action. The nurse should first address the patient's confusion and monitor her to see if the confusion persists or improves.

Has the child eaten recently? This is the correct and most important question to ask before administering insulin. The timing and content of the child's recent meals will directly impact their blood sugar levels and help determine the appropriate insulin dose. Insulin is typically administered in correlation with meals to maintain blood sugar within a target range and prevent hypo- or hyperglycemia.

A. Did the child perform a fingerstick? While checking the child's blood glucose level is an important part of diabetes management, it is not the most crucial piece of information to gather before administering insulin. The PN should prioritize knowing whether the child has eaten recently, as insulin administration should be coordinated with meals to prevent hypoglycemia or hyperglycemia.

B. How much did the child exercise today? Physical activity can affect blood sugar levels, but it is not the most critical information to obtain before administering insulin. The PN should focus on the child's food intake because insulin doses need to be adjusted accordingly to prevent fluctuations in blood sugar levels.

C. When did the child last urinate? While monitoring urinary patterns is important in assessing hydration and kidney function, it is not directly related to determining the appropriate insulin dose. The PN should prioritize gathering information about the child's recent food intake, as insulin administration needs to be coordinated with meals.