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 D
Explanation
Moving the client away from the stimuli in the dayroom and providing a calm environment, it may help to de-escalate the situation and reduce agitation. This action prioritizes the well-being of the client and helps to maintain a safe and therapeutic environment for all individuals involved.
A. Administer an as-needed (PRN) medication for agitation: Administering medication should not be the first action taken in this situation. It is important to first assess the client's condition and attempt to de-escalate the situation through non-pharmacological means. Medication should be considered if other interventions are ineffective or if there is an immediate risk of harm to the client or others.
B. Notify the client's healthcare provider: While it may be necessary to notify the client's healthcare provider about the situation, it is not the first action that should be implemented. The immediate priority is to ensure the safety of the client and those around them by providing support and supervision.
C. Escort the client to a calm and quiet place: Escorting the client to a calm and quiet place can be a helpful intervention, but it may not be the first action to take. It is important to first address the immediate safety concerns and attempt to de-escalate the situation. Once the client is calm and cooperative, they can be escorted to a more suitable environment if necessary.
Correct Answer is D
No explanation
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