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 A
Explanation
A. The client should maintain systolic BP between 120 and 129 mm Hg.
This is an appropriate recommendation. The American Heart Association (AHA) guidelines recommend maintaining systolic BP below 130 mm Hg to reduce the risk of stroke and other cardiovascular events in individuals with a history of stroke or TIA.
B. The client should maintain systolic BP between 130 and 135 mm Hg.
This is slightly above the recommended range. While systolic BP below 135 mm Hg is generally recommended for individuals with a history of stroke or TIA, a range of 130-135 mm Hg may still be acceptable based on individual patient factors and risk assessments.
C. The client should maintain systolic BP between 136 and 140 mm Hg.
This is above the recommended range. Systolic BP between 136 and 140 mm Hg may be considered elevated and should be managed to lower levels to reduce the risk of recurrent TIA or stroke.
D. The client should maintain systolic BP between 141 and 145 mm Hg.
This is above the recommended range. Systolic BP above 140 mm Hg is generally considered elevated and should be managed to lower levels to reduce the risk of recurrent TIA or stroke.
Correct Answer is C
Explanation
A. Instruct the client to perform controlled coughing and deep breathing.
This intervention is not appropriate for a client with increased intracranial pressure. Controlled coughing and deep breathing can increase intrathoracic pressure, which can in turn increase intracranial pressure. Therefore, this intervention should be avoided in clients with increased ICP.
B. Provide a brightly lit environment.
This intervention is not appropriate for a client with increased intracranial pressure. Bright lights can stimulate the reticular activating system and increase arousal, potentially exacerbating cerebral metabolic demand and intracranial pressure. Therefore, it is recommended to provide a calm, quiet environment with subdued lighting for clients with increased ICP.
C. Elevate the head of the bed 30°.
This intervention is correct. Elevating the head of the bed to 30 degrees promotes venous drainage from the head and reduces intracranial pressure. It helps prevent venous congestion in the brain and improves cerebral perfusion. This position is commonly used in clients with increased intracranial pressure to optimize cerebral blood flow.
D. Encourage a minimum intake of 2,000 mL/day of clear fluids.
This intervention is not appropriate for a client with increased intracranial pressure. While maintaining hydration is important for overall health, excessive fluid intake can increase intracranial pressure by increasing cerebral blood volume and cerebrospinal fluid production. Therefore, fluid intake should be carefully monitored and adjusted based on the client's condition and fluid balance.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today