Nokea
A patient who has been on long-term phenytoin (Dilantin) therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the patients plan of care?
- A. Monitoring of pulse oximetry
- B. Administration of a low-protein diet
- C. Administration of thorough oral hygiene
- D. Fluid restriction as ordered
Correct Answer: C
Rationale: Phenytoin can cause gingival hyperplasia, making thorough oral hygiene essential. Pulse oximetry, low-protein diet, and fluid restriction are not related to phenytoin's adverse effects.
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A hospital patient has experienced a seizure. In the immediate recovery period, what action best protects the patients safety?
- A. Place the patient in a side-lying position.
- B. Pad the patients bed rails.
- C. Administer antianxiety medications as ordered.
- D. Reassure the patient and family members.
Correct Answer: B
Rationale: A side-lying position prevents aspiration of secretions post-seizure. Padding rails, antianxiety drugs, or reassurance are secondary to airway safety.
What should the nurse suspect when hourly assessment of urine output on a patient postcraniotomy exhibits a urine output from a catheter of 1,500 mL for two consecutive hours?
- A. Cushing syndrome
- B. Syndrome of inappropriate antidiuretic hormone (SIADH)
- C. Adrenal crisis
- D. Diabetes insipidus
Correct Answer: D
Rationale: High urine output post-craniotomy suggests diabetes insipidus, common after brain surgery. Cushing syndrome and SIADH cause fluid retention, and adrenal crisis causes hypovolemia.
An adult patient has sought care for the treatment of headaches that have become increasingly severe and frequent over the past several months. Which of the following questions addresses potential etiological factors? Select all that apply.
- A. Are you exposed to any toxins or chemicals at work?
- B. How would you describe your ability to cope with stress?
- C. What medications are you currently taking?
- D. When was the last time you were hospitalized?
- E. Does anyone else in your family struggle with headaches?
Correct Answer: A,B,C, E
Rationale: Headaches are multifactorial; toxins, stress, medications, and family history contribute. Hospitalization is not a direct etiological factor.
A patient is recovering from intracranial surgery that was performed using the transsphenoidal approach. The nurse should be aware that the patient may have required surgery on what neurologic structure?
- A. Cerebellum
- B. Hypothalamus
- C. Pituitary gland
- D. Pineal gland
Correct Answer: C
Rationale: The transsphenoidal approach accesses the pituitary gland via the nasal cavity. The cerebellum, hypothalamus, and pineal gland are not reached this way.
The nurse is providing care for a patient who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the patient has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following?
- A. The ability of the patient to follow instructions during the seizure.
- B. The success or failure of the care team to physically restrain the patient.
- C. The patients ability to explain his seizure during the postictal period.
- D. The patients activities immediately prior to the seizure.
Correct Answer: D
Rationale: Documenting pre-seizure activities helps identify triggers. Patients cannot follow instructions or explain seizures during or postictally, and restraint is contraindicated.