Nokea
A nurse is caring for a client with seizure disorders who is admitted to the health care facility. The client is prescribed phenytoin. During therapy, which of the following would be most important for the nurse to include in the ongoing assessment?
- A. Check the client's temperature every 3 to 4 hours
- B. Obtain serum plasma drug levels regularly
- C. Assess the client's respiratory rate
- D. Evaluate the client's pulse rate and rhythm
Correct Answer: B
Rationale: Although vital signs such as temperature, pulse rate and rhythm, and respiratory rate are commonly assessed routinely, it would be most important for the nurse to obtain serum plasma drug levels to evaluate the effectiveness of the therapy and also to prevent possible toxicity. Unless the client's vital signs are not within normal parameters, the nurse would monitor them based on the facility's policy.
You may also like to solve these questions
After teaching a client and family about prescribed phenytoin therapy, the nurse determines that the teaching was successful when they identify that which of the following should be reported to the primary health care provider as possibly indicating toxicity? Select all that apply.
- A. Ataxia
- B. Nystagmus
- C. Slurred speech
- D. Lethargy
- E. Diplopia
Correct Answer: A,C,D
Rationale: Signs suggesting phenytoin toxicity that need to be reported include slurred speech, ataxia, lethargy, dizziness, nausea, and vomiting.
A primary health care provider prescribes phenytoin to be administered parenterally to a client with a seizure disorder. The nurse prepares the drug to be given by which method?
- A. Intradermally
- B. Subcutaneously
- C. Intramuscularly
- D. Intravenously
Correct Answer: D
Rationale: Phenytoin can be administered orally and parenterally. If the drug is administered parenterally, the intravenous (IV) route is preferred over the intramuscular (IM) route, because with the IM route erratic absorption of phenytoin causes pain and muscle damage at the injection site. The drug is not administered intradermally or subcutaneously.
A nurse is preparing to administer phenytoin to a client. The nurse understands the need to administer this drug cautiously if the client has a history of which of the following? Select all that apply.
- A. Hyperthyroidism
- B. Hypotension
- C. Diabetes
- D. Asthma
- E. Hepatic impairment
Correct Answer: B,E
Rationale: Phenytoin (Dilantin) is used cautiously in clients with hypotension, severe myocardial insufficiency, and hepatic impairment.
A client comes to the clinic for a follow-up visit. The client is prescribed lamotrigine for seizure control. The nurse suspects that the client may be experiencing Stevens-Johnson syndrome based on which of the following?
- A. Complaints of muscle pain
- B. Lesions on the mucous membranes
- C. Blisters on the face and neck
- D. Recurrence of seizure activity
- E. Dizziness
Correct Answer: A,B,C
Rationale: Stevens-Johnson syndrome (SJS) is manifested by fever, cough, muscular aches and pains, headache, and lesions of the skin, mucous membranes, and eyes; the lesions appear as red wheals or blisters, often starting on the face, in the mouth, or on the lips, neck, and extremities. Recurrence of seizure activity and dizziness are not associated with this condition.
A nurse is caring for a client who is prescribed carbamazepine. When reviewing the client's medical record, the nurse would notify the health care provider for a change in the order if the client has which of the following?
- A. Bipolar disorder
- B. Renal impairment
- C. Hearing impairment
- D. Respiratory depression
Correct Answer: B
Rationale: Carbamazepine is contraindicated among clients with renal impairment. It can be prescribed to treat bipolar disorder. The drug is not contraindicated in clients with hearing impairment or respiratory depression.