Which condition would indicate to the nurse that the patient has a phenytoin (Dilantin) toxicity?

Nystagmus

Strabismus

Blurry vision

Amblyopia

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Aura phase:

The aura phase occurs before the seizure and is characterized by subjective sensations or experiences that some individuals may have. It serves as a warning sign that a seizure is about to occur. This phase precedes the seizure itself and is not applicable to the period immediately afterward.

B. Presence of automatisms:

Automatisms refer to repetitive, involuntary movements or actions that some individuals may exhibit during certain types of seizures, such as complex partial seizures. They are not typically observed during the postictal phase of a generalized tonic-clonic seizure.

C. Postictal phase:

The postictal phase, also known as the postictal state, refers to the period following a seizure during which the individual may experience confusion, drowsiness, or other altered states of consciousness. This phase typically lasts for minutes to hours and is characterized by gradual recovery of normal function.

D. Presence of absence seizures:

Absence seizures are characterized by brief episodes of altered consciousness, often manifesting as staring spells or momentary loss of awareness. They are distinct from generalized tonic-clonic seizures and do not involve the same postictal phase characterized by drowsiness and altered arousal.

A. "Have you had an MMR immunization?" B. "Have you had a recent upper respiratory infection?" C. "Have you traveled overseas recently?" D. "Are you taking a multivitamin?"

Correct Answer is B

Explanation

A. "Have you had an MMR immunization?"

This question is not directly relevant to the assessment of Guillain-Barré syndrome. MMR immunization history may be pertinent to other health assessments, such as immunity to measles, mumps, and rubella.

B. "Have you had a recent upper respiratory infection?"

This is the correct answer. GBS often occurs after a recent upper respiratory or gastrointestinal infection, so asking about recent illnesses can provide valuable information for diagnosis.

C. "Have you traveled overseas recently?"

While travel history may be relevant to certain infectious diseases, it is not typically associated with the development of Guillain-Barré syndrome. Therefore, this question is less pertinent in this context.

D. "Are you taking a multivitamin?"

The use of multivitamins is unlikely to be directly related to the development of Guillain-Barré syndrome. While nutritional status is important for overall health, it is not a primary focus when assessing for GBS.

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Which condition would indicate to the nurse that the patient has a phenytoin (Dilantin) toxicity?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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