Nokea
A nurse is developing a plan of care for a client receiving anticonvulsant therapy and identifies a nursing diagnosis of Risk for Injury. Which assessment findings would support this nursing diagnosis? Select all that apply.
- A. Epistaxis
- B. Reports of blurred vision
- C. Complaints of dizziness
- D. Photosensitivity
- E. Scaling red rash
Correct Answer: B,C,D
Rationale: A client would be at risk for injury if the client was experiencing blurred vision, dizziness, and photosensitivity. Epistaxis would support a nursing diagnosis of a possible Risk for Injury related to a reduction in platelets from hematologic adverse reactions. A scaling red rash would support a nursing diagnosis of Impaired Skin Integrity.
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The primary health care provider prescribes diazepam 10 mg IV to be administered to a client to control his seizures. The nurse would administer this drug over which time frame?
- A. 1 minute
- B. 2 minutes
- C. 5 minutes
- D. 10 minutes
Correct Answer: B
Rationale: When used to control seizures, diazepam is administered IV pushed slowly as close as possible to the IV site, allowing at least 1 minute for each 5 mg of drug. For a dosage of 10 mg, the nurse would administer the drug over 2 minutes.
The nurse is assessing a client for gingival hyperplasia based on the understanding that this adverse reaction is commonly associated with long-term administration of which of the following? Select all that apply.
- A. Carbamazepine (Tegretol)
- B. Phenytoin (Dilantin)
- C. Valproic acid (Depakote)
- D. Felbamate (Felbatol)
- E. Ethotoin (Peganone)
Correct Answer: B,E
Rationale: Gingival hyperplasia, although it can occur with any anticonvulsant, is commonly associated with long-term hydantoin therapy such as with phenytoin or ethotoin.
The nurse would closely monitor a client taking which of the following anticonvulsants for pancytopenia? Select all that apply.
- A. Carbamazepine (Tegretol)
- B. Phenytoin (Dilantin)
- C. Valproic acid (Depakote)
- D. Felbamate (Felbatol)
- E. Zonisamide (Zonegran)
Correct Answer: A,D
Rationale: A client taking carbamazepine (Tegretol) or felbamate (Felbatol) should be monitored closely for pancytopenia.
After reviewing information about anticonvulsants, a nursing student demonstrates understanding of this group of drugs, identifying which of the following as acting to elevate the seizure threshold by decreasing postsynaptic excitation? Select all that apply.
- A. Clonazepam (Klonopin)
- B. Valproic acid (Depakote)
- C. Gabapentin (Neurontin)
- D. Lorazepam (Ativan)
- E. Trimethadione (Tridione)
Correct Answer: A,D
Rationale: Benzodiazepines (clonazepam and lorazepam) exert their effect by elevating the seizure threshold by decreasing postsynaptic excitation. Valproic acid increases the levels of GABA, gabapentin is a GABA agonist, and trimethadione decreases the repetitive synaptic transmission of nerve impulses.
A nurse monitoring a client taking trimethadione should notify the primary health care provider if assessment reveals which of the following? Select all that apply.
- A. Visual disturbances
- B. Fever
- C. Easy bruising
- D. Dry mouth
- E. Sore throat
Correct Answer: A,B,C,E
Rationale: A nurse monitoring a client taking trimethadione should notify the primary health care provider if visual disturbances, excessive drowsiness or dizziness, sore throat, fever, skin rash, pregnancy, malaise, easy bruising, epistaxis, or bleeding is observed.