What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?

Bladder palpation.

Blood glucose monitoring.

Inspection of the mouth.

Auscultation of breath sounds.

Answer and Explanation

The Correct Answer is C

Choice A: This is not specifically related to the side effects of phenytoin.

Choice B: This is not directly related to the common side effects of phenytoin, which primarily affect the oral cavity.

Choice C: Phenytoin (Dilantin) is known to cause gingival hyperplasia (enlargement of the gums) as a common side effect. The nurse should regularly inspect the client's mouth to monitor for this adverse effect.

Choice D: This is not specifically relevant to monitoring for phenytoin's side effects.

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Correct Answer is B

Explanation

Choice A: This is important for the client's overall health but is not the most immediate priority in managing diabetes.

Choice B: The most important intervention for this client is to address lifestyle factors that contribute to diabetes and overall health. Weight loss and dietary changes are key components of managing type 2 diabetes. The client's weight is significantly above a healthy range, and losing 2 pounds (1 kg) per week is a reasonable and safe goal.

Choice C: Encouraging family members to be tested for diabetes is relevant but does not directly address the client's own management of the condition.

Choice D: Determining the client's feelings about the diagnosis is important for emotional support but does not directly address the client's physical health and diabetes management.

A. Apply compression stockings before ambulation. B. Soak feet to soften nails before trimming. C. Keep legs dependent to promote blood flow. D. Medicate inflamed skin areas with an antibiotic ointment.

Correct Answer is A

Explanation

Choice A: Applying compression stockings before ambulation is a key aspect of self-care for a client with chronic venous insufficiency. Compression stockings help improve venous return and reduce edema.

Choice B: Soaking feet to soften nails before trimming is not a specific intervention for chronic venous insufficiency and should be done with caution in individuals with open ulcers.

Choice C: Keeping legs dependent to promote blood flow is not advisable in chronic venous insufficiency, as it can worsen venous pooling and edema.

Choice D: Medicating inflamed skin areas with an antibiotic ointment may be part of wound care but does not address the primary intervention of using compression stockings for chronic venous insufficiency.

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What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

When assessing both lower extremities (BLE) of a client who has chronic venous insufficiency, the nurse identifies bilateral stasis dermatitis and an ulcer on the medial surface of the left ankle. To promote effective self-care, which client teaching should the nurse provide?

Correct Answer is A

Explanation

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