The nurse reviews laboratory results for a client with a traumatic brain injury prescribed phenytoin.
The nurse notes the phenytoin level is 32 mg/dL (normal range 10-20 mg/dL). Which findings should the nurse anticipate? Select all that apply.

Nystagmus.

Hypoglycemia.

Ataxia.

Vertigo.

High platelet level.

Answer and Explanation

Correct Answer : A,C,D

This case involves phenytoin toxicity resulting from a level exceeding the therapeutic range of 10 to 20 mg/dL. Knowledge of central nervous system effects, pharmacokinetics, and toxicological manifestations of anticonvulsants is necessary to identify appropriate neurological assessment findings.

Choice A rationale

Nystagmus, or involuntary eye movement, is a classic sign of phenytoin toxicity as levels rise above 20 mg/dL. It results from the drug's effect on the cerebellum and vestibular system, disrupting normal extraocular muscle coordination and balance.

Choice B rationale

Phenytoin typically causes hyperglycemia rather than hypoglycemia because it inhibits insulin secretion. A serum level of 32 mg/dL would not be expected to lower blood glucose; monitoring for elevated glucose levels is more appropriate in toxicity.

Choice C rationale

Ataxia involves uncoordinated muscle movements and gait instability, frequently occurring when phenytoin levels exceed therapeutic limits. The drug affects cerebellar function, leading to significant motor impairment and increasing the client's risk for falls and physical injury.

Choice D rationale

Vertigo or dizziness is a common central nervous system side effect of high phenytoin concentrations. As the drug reaches toxic levels like 32 mg/dL, it interferes with vestibular signaling, causing the sensation of spinning or loss of balance.

Choice E rationale

Phenytoin toxicity is more likely to cause blood dyscrasias like leukopenia or thrombocytopenia rather than a high platelet level. Normal platelet counts are 150,000 to 400,000 cells/mm; high levels are not a recognized manifestation of phenytoin overdose.

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Correct Answer is A

Explanation

Hyperkalemia management involves identifying medications that facilitate the removal of potassium from the body. Understanding the mechanism of action of various renal and GI medications is necessary. This prevents cardiac arrest by lowering potassium toward the 3.5 to 5.0 mEq/L range.

Choice A rationale

This medication is a cation exchange resin that works in the intestine. It exchanges sodium ions for potassium ions, allowing the potassium to be excreted through the feces. It is specifically indicated for treating high serum potassium levels.

Choice B rationale

Lactulose is an osmotic laxative primarily used to reduce serum ammonia levels in clients with hepatic encephalopathy. It promotes the excretion of ammonia through the stool but has no significant effect on lowering serum potassium levels.

Choice C rationale

This medication is an erythropoiesis stimulating agent used to treat anemia associated with chronic kidney disease. It stimulates red blood cell production in the bone marrow but does not influence electrolyte levels or treat acute hyperkalemia.

Choice D rationale

Sevelamer is a phosphate binder used to manage hyperphosphatemia in clients with chronic kidney disease. It prevents the absorption of dietary phosphorus in the gut but does not have a mechanism to lower serum potassium concentrations.

A. A client 1 day post-op with a temperature of 38.2°C (100.9°F). B. A client with pancreatitis reporting abdominal pain 8/10 and nausea. C. A client with cirrhosis who is increasingly confused and has asterixis. D. A client with a potassium level of 6.8 mEq/L who has peaked T waves on ECG.

Correct Answer is D

Explanation

Nursing prioritization relies on the ABC framework and identifying the most immediate threat to life. Knowledge of electrolyte imbalances and cardiac conduction must be applied here to recognize that severe hyperkalemia poses an imminent risk of lethal cardiac arrhythmias.

Choice A rationale

A low grade fever of 38.2 C on the first postoperative day is common due to the inflammatory response or atelectasis. While it requires monitoring and lung expansion exercises, it is not an immediate life threat.

Choice B rationale

Severe abdominal pain and nausea are classic symptoms of acute pancreatitis. While the patient is in significant distress and needs analgesia, this presentation is expected for the diagnosis and is second to cardiovascular instability.

Choice C rationale

Confusion and asterixis in cirrhosis indicate hepatic encephalopathy due to elevated ammonia. Normal ammonia is 15 to 45 mcg/dL. This requires treatment with lactulose but is less immediately fatal than a cardiac arrest.

Choice D rationale

A potassium level of 6.8 mEq/L is critically high, as the normal range is 3.5 to 5.0 mEq/L. Peaked T waves indicate myocardial irritability, which can progress rapidly to ventricular fibrillation or asystole, requiring emergent intervention..

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The nurse reviews laboratory results for a client with a traumatic brain injury prescribed phenytoin. The nurse notes the phenytoin level is 32 mg/dL (normal range 10-20 mg/dL). Which findings should the nurse anticipate? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory report of a client and identifies a serum potassium level of 6.8 mEq/L. Which of the following medications should the nurse plan to administer?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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The nurse reviews laboratory results for a client with a traumatic brain injury prescribed phenytoin.
The nurse notes the phenytoin level is 32 mg/dL (normal range 10-20 mg/dL). Which findings should the nurse anticipate? Select all that apply.