Which information about a patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication?

Patient has slight elevations in liver function test results

Patient's most recent blood pressure is 156/92 mm Hg.

Patient experiences an aura before seizures.

Patient has tonic-clonic seizures.

Answer and Explanation

The Correct Answer is A

A. Patient has slight elevations in liver function test results: Phenytoin is primarily metabolized by the liver, and elevated liver function tests may indicate impaired liver function, potentially affecting the metabolism and clearance of phenytoin. Consultation with the healthcare provider is warranted to assess the risk-benefit ratio of administering phenytoin in the presence of liver function abnormalities.

B. Patient's most recent blood pressure is 156/92 mm Hg: While hypertension is not a contraindication for phenytoin administration, it is important to monitor blood pressure, especially considering the potential cardiovascular side effects of the medication. However, elevated blood pressure alone does not typically warrant consultation before administering phenytoin.

C. Patient experiences an aura before seizures: Experiencing an aura before seizures is a common phenomenon in patients with epilepsy and does not necessarily contraindicate the use of phenytoin. In fact, phenytoin is commonly prescribed to prevent seizures, including those preceded by an aura.

D. Patient has tonic-clonic seizures: Phenytoin is indicated for the treatment and prevention of tonic-clonic seizures, among other seizure types. Therefore, the presence of tonic-clonic seizures would not typically warrant consultation before administering phenytoin.

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Correct Answer is B

Explanation

A. Remove clothing: While removing clothing may be necessary for a thorough assessment and treatment, maintaining cervical spine precaution takes precedence to prevent potential spinal cord injury in clients with a history of trauma, such as a fall from a significant height.

B. Maintain cervical spine precaution: Maintaining cervical spine precaution by stabilizing the cervical spine and immobilizing the neck is crucial to prevent further injury to the spinal cord in clients with a history of trauma until spinal injury is ruled out or managed.

C. Perform a mental status exam: While assessing the client's mental status is important for evaluating neurological function, it is not the first priority in a client with potential spinal cord injury following a fall.

D. Assess for facial lacerations: Assessing for facial lacerations is important for identifying and managing potential facial injuries, but it is not the first priority in the primary assessment of a client with a history of trauma and potential spinal cord injury.

A. Place suction equipment at the client's bedside. B. Provide range-of-motion exercises to the client's neck and shoulders. C. Apply an eye patch to the client's right eye. D. Avoid the use of warm water to wash the client's face.

Correct Answer is A

Explanation

A. Place suction equipment at the client's bedside: Impairment of cranial nerves IX and X can lead to difficulty swallowing and impaired gag reflex, increasing the risk of aspiration and airway obstruction. Therefore, having suction equipment readily available is essential to maintain a patent airway and manage secretions effectively.

B. Provide range-of-motion exercises to the client's neck and shoulders: While range-of-motion exercises may be beneficial for preventing muscle stiffness and contractures, they are not directly related to the client's risk of airway compromise or aspiration.

C. Apply an eye patch to the client's right eye: Acoustic neuroma typically affects cranial nerves VII and VIII, leading to symptoms such as hearing loss and facial weakness. Applying an eye patch to the client's right eye is not necessary for cranial nerve IX and X impairment unless there are specific ocular symptoms.

D. Avoid the use of warm water to wash the client's face: Warm water may be used to wash the client's face safely and is not contraindicated specifically for a client with impairment of cranial nerves IX and X. However, precautions should be taken to ensure that water does not enter the airway if the client has difficulty swallowing or impaired gag reflex.

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Which information about a patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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