Nokea
A client with epilepsy is taking phenytoin. What long-term effects should the nurse advise the client can occur with prolonged administration of phenytoin? Select all that apply.
- A. Gingival hypertrophy
- B. Hirsutism
- C. Hypertrophy of facial subcutaneous tissue
- D. Dementia
- E. Anemia
Correct Answer: A,B,E
Rationale: Phenytoin's long-term effects include gingival hypertrophy (A), hirsutism (B), and anemia (E). Facial hypertrophy (C) and dementia (D) are not associated with phenytoin.
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A client with a history of phenylketonuria is seen at the local family planning clinic. After completing the client's intake history, the nurse provides literature for a healthy pregnancy. Which statement indicates that the client needs further teaching?
- A. I can help control my weight by switching from sugar to Nutrasweet.
- B. I need to resume my old diet before becoming pregnant.
- C. Fresh fruits and raw vegetables will make excellent betweenmeal snacks.
- D. I need to eliminate most sources of phenylalanine from my diet.
Correct Answer: A
Rationale: Nutrasweet (aspartame) contains phenylalanine, which must be avoided in phenylketonuria, indicating a need for further teaching.
A nurse notes that clients of one surgeon have developed at least twice as many infections as clients of other surgeons on the unit. Which of the following is the most appropriate action?
- A. Report the physician to the hospital administration.
- B. Ask the physician why his rate of infections is so high.
- C. Report the observations to the infection control nurse.
- D. Say nothing as infection rates vary from time to time.
Correct Answer: C
Rationale: Reporting to the infection control nurse (C) initiates investigation and intervention. Reporting to administration (A) or confronting the physician (B) is premature, and ignoring the issue (D) is unsafe.
Which action is contraindicated in the client with epiglottis?
- A. Ambulation
- B. Oral airway assessment using a tongue blade
- C. Placing a blood pressure cuff on the arm
- D. Checking the deep tendon reflexes.
Correct Answer: B
Rationale: Using a tongue blade can trigger airway obstruction in epiglottitis, making it contraindicated.
A burn client begins treatments with silver sulfadiazine (Silvadene) applied to the wounds. The nurse should carefully monitor for which adverse affect associated with this drug?
- A. Hypokalemia
- B. Leukopenia
- C. Hyponatremia
- D. Thrombocytopenia
Correct Answer: B
Rationale: Silver sulfadiazine can cause leukopenia as an adverse effect, requiring monitoring of white blood cell counts to detect potential bone marrow suppression.
A client is receiving oxygen therapy at 3 L/min per nasal cannula. Which of the following fraction of inspired oxygen (FiO2) measurements does the nurse expect that the client is receiving?
- A. 24%.
- B. 60%.
- C. 32%.
- D. 100%.
Correct Answer: C
Rationale: Nasal cannula at 3 L/min delivers approximately 32% FiO2 (C), as each liter increases FiO2 by about 4% above room air (21%). Other percentages (A, B, D) do not correspond to this flow rate.