Which condition would indicate to the nurse that the patient has a phenytoin (Dilantin) toxicity?
Nystagmus
Strabismus
Blurry vision
Amblyopia
The Correct Answer is A
A. Nystagmus:
Nystagmus is an involuntary, rhythmic movement of the eyes, which can be rapid and jerky. It is a common neurological manifestation of phenytoin toxicity. Patients experiencing phenytoin toxicity may exhibit horizontal or vertical nystagmus, which can be detected upon physical examination.
B. Strabismus:
Strabismus, also known as crossed eyes or squint, refers to a misalignment of the eyes. While strabismus can have various causes, it is not typically associated with phenytoin toxicity. Therefore, it is less likely to indicate phenytoin toxicity compared to nystagmus.
C. Blurry vision:
Blurry vision, or visual disturbances, can occur in patients experiencing phenytoin toxicity. However, it is a non-specific symptom and can be observed in various other conditions as well. Patients with phenytoin toxicity may experience blurry vision, double vision (diplopia), or other visual disturbances due to the effects of the medication on the central nervous system.
D. Amblyopia:
Amblyopia, also known as lazy eye, is a condition characterized by reduced vision in one or both eyes. It is typically associated with visual development during childhood and is not directly related to phenytoin toxicity. Therefore, it is less likely to indicate phenytoin toxicity compared to nystagmus or other neurological manifestations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["15"]
Explanation
To calculate the dose of phenytoin suspension, the nurse should use the following formula:
Dose (mL) = Desired dose (mg) / Concentration (mg/mL) x Volume (mL)
Plugging in the values from the question, we get:
Dose (mL) = 75 mg / (25 mg/5 mL) x 5 mL
Dose (mL) = 15 mL
Therefore, the nurse should administer 15 mL of phenytoin suspension to the patient
Correct Answer is ["A","B","D"]
Explanation
A. Provide a suction setup at the bedside:
This is a relevant intervention as it ensures that suction equipment is readily available in case the client experiences excessive secretions or vomiting during or after a seizure. It helps maintain a clear airway and prevent aspiration.
B. Elevate the side rails when in bed:
Elevating the side rails can help ensure the client's safety during a seizure by preventing falls from the bed. It is a preventive measure to minimize the risk of injury.
C. Place a bite stick at the bedside:
Placing a bite stick at the bedside is not a recommended intervention. Bite sticks can potentially injure the patient's teeth or mouth during a seizure and are generally not recommended in current practice.
D. Keep an oxygen setup at the bedside:
This is an appropriate intervention as it ensures that oxygen is readily available in case the client experiences respiratory distress or hypoxia during or after a seizure. Oxygen therapy may be needed to support respiratory function.
E. Furnish restraints at the bedside:
Furnishing restraints at the bedside is not a recommended intervention for managing seizures. Restraints should only be used in exceptional circumstances when the client's safety or the safety of others is at risk and should be applied according to institutional policies and legal regulations.
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