Nokea
Assessment of a client receiving anticonvulsant therapy reveals the following: sore throat, chills, fever, gingival bleeding, and bruising. Which nursing diagnosis would the nurse most likely identify?
- A. Risk for Impaired Skin Integrity
- B. Impaired Oral Mucous Membranes
- C. Risk for Injury
- D. Risk for Infection
Correct Answer: D
Rationale: The assessment findings suggest pancytopenia, so Risk for Infection would be most likely. Risk for Impaired Skin Integrity would be appropriate if the client developed a rash. Impaired Oral Mucous Membranes would be appropriate if the client was exhibiting signs of gingival hyperplasia. Risk for Injury would be appropriate if the client was experiencing drowsiness, ataxia, and vision disturbances related to the drug therapy.
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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.
An older adult client is prescribed diazepam for seizure control. Which of the following would be most important for the nurse to monitor?
- A. Respiratory rate and depth
- B. Blood glucose levels
- C. Swallowing ability
- D. Speech quality
Correct Answer: A
Rationale: Apnea and cardiac arrest can occur when diazepam is administered to older adults, very ill patients, and individuals with limited pulmonary reserve. Therefore, monitoring the client's respiratory rate and depth would be most important. There is no need to monitor the client's blood glucose levels, swallowing ability, or speech quality unless these were issues before this drug therapy was initiated.
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.
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.
A nurse understands that lorazepam (Ativan) is the drug of choice for treating status epilepticus but that its effects last for less than 1 hour. The nurse would expect which of the following to be prescribed along with lorazepam (Ativan) during status epilepticus? Select all that apply.
- A. Ethosuximide (Zarontin)
- B. Phenytoin (Dilantin)
- C. Ethotoin (Peganone)
- D. Zonisamide (Zonegran)
Correct Answer: B
Rationale: Due to the short effects of lorazepam (Ativan), a longer-acting anticonvulsant, such as phenytoin (Dilantin), is given to continue control of seizure activity.