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","E"]
Explanation
Correct:
B- Making these changes will also help me avoid other chronic health conditions. This statement indicates an understanding because the client recognizes that the lifestyle changes discussed will not only help prevent or manage diabetes but also have a positive impact on other chronic health conditions such as cardiovascular disease and obesity.
E- If I have symptoms like increased thirst and urination, I should come in and get my blood sugar checked. This statement indicates an understanding because the client acknowledges the importance of monitoring their blood sugar levels if they experience symptoms commonly associated with diabetes, such as increased thirst and urination.
Incorrect choices:
A- If my fasting blood sugar is less than 100 next time, I can go back to my usual eating habits. This statement indicates a misunderstanding. It suggests that as long as the client's fasting blood sugar is below 100, they can resume their previous eating habits, which is not accurate. It's important to emphasize that long-term lifestyle changes are necessary, regardless of individual blood sugar readings.
C- I can never eat sugar again. This statement indicates a misunderstanding. While it's important to minimize the consumption of sugary foods and beverages, it's not necessary to completely eliminate all sugar from the diet. Moderation and mindful consumption are key.
D- If I make the changes we talked about, I will not get type 2 diabetes. This statement indicates a misunderstanding. While making positive lifestyle changes can significantly reduce the risk of developing type 2 diabetes, it does not guarantee complete prevention. Genetic and other factors can still influence an individual's susceptibility to the condition.
Correct Answer is D
Explanation
This is the action that the PN should implement for a male client who has just been told he has cancer and asks to be left alone. Leaving the room after offering to return later respects the client's autonomy and privacy, while also showing empathy and availability. The client may need some time and space to process the diagnosis and cope with his emotions. The PN should not force the client to talk or stay with him if he does not want to, but should also not abandon him or ignore his needs.
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