The nurse is caring for a client with a new diagnosis of epilepsy who is prescribed phenytoin. Which teaching point should the nurse emphasize?

Avoid alcohol consumption

Increase calcium intake

Limit physical activity

Reduce fluid intake

Answer and Explanation

The Correct Answer is A

Choice A reason: Avoiding alcohol is critical with phenytoin, as it increases seizure risk and alters drug metabolism, reducing efficacy or causing toxicity. Alcohol’s CNS depressant effects exacerbate epilepsy, making this the priority teaching point to ensure seizure control and medication safety.

Choice B reason: Increasing calcium intake is unrelated to phenytoin or epilepsy management. While phenytoin may affect bone health long-term, alcohol avoidance is more urgent, as it directly impacts seizure control and drug pharmacokinetics, making it the priority teaching focus.

Choice C reason: Limiting physical activity is unnecessary for epilepsy unless seizures are poorly controlled. Alcohol avoidance is critical, as it lowers the seizure threshold and interferes with phenytoin metabolism, posing immediate risks to seizure control, making it the primary teaching point.

Choice D reason: Reducing fluid intake is irrelevant to phenytoin or epilepsy. Proper hydration supports health, but alcohol avoidance is the priority, as it directly affects seizure risk and phenytoin’s effectiveness, ensuring therapeutic levels and preventing breakthrough seizures in epilepsy management.

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Correct Answer is C

Explanation

Choice A reason: Teaching mask use, hand washing, and distancing is important for preventing COVID-19 spread but is secondary to immediate isolation. Suspected cases require prompt separation to minimize transmission risk, as symptoms like fever and anosmia suggest high infectivity, making isolation the priority action.

Choice B reason: Counseling family to monitor symptoms is a follow-up measure, not the immediate priority. Isolation prevents active transmission in the emergency department, where the client is currently located. Family monitoring is relevant post-discharge but secondary to containing the virus in the acute setting.

Choice C reason: Isolation is the most critical action for a suspected COVID-19 case, as symptoms like fever, anosmia, and aches indicate potential infectivity. Separating the client from others without proper PPE prevents airborne and droplet transmission, protecting patients and staff in the emergency department, making it the priority.

Choice D reason: Reporting COVID-19 results to health authorities is mandatory but occurs after test confirmation. Immediate isolation prevents transmission in the emergency department while awaiting results. Reporting is a secondary administrative action, as the priority is containing the virus in the acute care setting.

A. Provide a numeric pain scale B. Observe body language and movement C. Ask the client to describe the pain D. Identify effective pain relief measures

Correct Answer is C

Explanation

Choice A reason: A numeric pain scale quantifies pain intensity but not its quality, such as burning or stabbing. Descriptive data provide a fuller picture of pain characteristics, which guide treatment. Numbers alone lack the detail needed to assess the nature of the pain experience.

Choice B reason: Observing body language and movement, like grimacing or guarding, indicates pain presence but not its specific quality. Subjective descriptions from the client reveal characteristics like sharpness or throbbing, which are critical for diagnosis and management, making observation secondary to verbal reports.

Choice C reason: Asking the client to describe the pain captures its quality, including type, location, and pattern (e.g., burning, stabbing). This subjective data is essential for diagnosing the pain’s cause and tailoring treatment, as it provides detailed insights beyond intensity or observable signs, making it the best approach.

Choice D reason: Identifying effective pain relief measures is part of pain management, not assessment of pain quality. Understanding the pain’s characteristics through description is necessary before selecting interventions. This approach is premature without first gathering detailed subjective data from the client.

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The nurse is caring for a client with a new diagnosis of epilepsy who is prescribed phenytoin. Which teaching point should the nurse emphasize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Explanation

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