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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

A.

Ataxia

B.

Drowsiness

C.

Altered blood coagulation

D.

Anxiety

E.

Aphasia

F.

Vertigo

G.

Visual disturbances

H.

Vomiting

Answer and Explanation

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.


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Related Questions

Correct Answer is D

Explanation

Regular insulin is the medication of choice for treating DKA. Its main action is to lower blood glucose levels by promoting the uptake of glucose into cells and inhibiting the production of glucose by the liver. Therefore, checking the fingerstick blood glucose level is an important indicator of the effectiveness of the insulin treatment.
A decrease in the blood glucose level indicates that the insulin is working to lower the high blood sugar associated with DKA. This measurement helps the PN assess the response to treatment and adjust the insulin dosage if necessary.
The other actions mentioned are also important assessments in the care of a client with DKA, but they do not specifically evaluate the effectiveness of the insulin dosage:
A. Smelling the client's breath for resolution of a fruity odor is important as it indicates a decrease in ketone production, which is a marker of improving DKA. However, it does not directly evaluate the effectiveness of the insulin dosage.
B. Determining the client's orientation to time and space is part of assessing their neurological status, which is crucial in managing DKA. However, it does not specifically assess the effectiveness of the insulin dosage.
C. Measuring the client's urinary output for an increased volume is important to monitor hydration status and renal function, but it does not directly evaluate the effectiveness of the insulin dosage.

Correct Answer is ["600"]

Explanation

To calculate the total intake in milliliters:

  • 4 ounces apple juice → 4 × 30 = 120 mL
  • 8 ounces milk → 8 × 30 = 240 mL
  • 4 ounces broth → 4 × 30 = 120 mL
  • 4 ounces tea → 4 × 30 = 120 mL

Total intake: 120 + 240 + 120 + 120 = 600 mL

Answer:
600

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