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The client is prescribed phenytoin (Dilantin), an anticonvulsant, for a seizure disorder. Which statement indicates the client understands the discharge teaching concerning this medication?
- A. I will brush my teeth after every meal.'
- B. I will check my Dilantin level daily.'
- C. My urine will turn orange while on Dilantin.'
- D. I won’t have any seizures while on this medication.'
Correct Answer: A
Rationale: Phenytoin can cause gingival hyperplasia, so good oral hygiene (A) is essential and indicates understanding. Dilantin levels (B) are checked periodically by providers, not daily. Urine color change (C) is not typical, and seizures may still occur (D) if not fully controlled.
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The nurse is caring for the client diagnosed with West Nile virus. Which assessment data would require immediate intervention from the nurse?
- A. The vital signs are documented as T 100.2°F, P 80, R 18, and BP 136/78.
- B. The client complains of generalized body aches and pains.
- C. Positive results are reported from the enzyme-linked immunosorbent assay (ELISA).
- D. The client becomes lethargic and is difficult to arouse using verbal stimuli.
Correct Answer: D
Rationale: Lethargy and difficulty arousing (D) indicate neurological deterioration, requiring immediate intervention. Mild fever (A), body aches (B), and positive ELISA (C) are expected.
The client admitted to the hospital to rule out encephalitis is being prepared for a lumbar puncture. Which instructions should the nurse teach the client regarding care postprocedure?
- A. Instruct that all invasive procedures require a written permission.
- B. Explain that this allows analysis of a sample of the cerebrospinal fluid.
- C. Tell the client to increase fluid intake to 300 mL for the next 48 hours.
- D. Discuss that lying supine with the head flat will prevent all hematomas.
Correct Answer: C
Rationale: Post-lumbar puncture, increasing fluid intake (C) helps replace CSF and prevent headaches. Consent (A) is preoperative, CSF analysis (B) explains purpose, and lying flat (D) prevents headaches, not hematomas.
The public health nurse is discussing St. Louis encephalitis with a group in the community. Which instruction should the nurse provide to help prevent an outbreak?
- A. Yearly vaccinations for the disease.
- B. Advise that the city should spray for mosquitoes.
- C. The use of gloves when gardening.
- D. Not going out at night.
Correct Answer: B
Rationale: St. Louis encephalitis is mosquito-borne. Mosquito spraying (B) reduces vector populations. No vaccine exists (A), gloves (C) are irrelevant, and night avoidance (D) is less effective.
Which assessment finding in a client post-diskectomy indicates a potential complication?
- A. Mild incisional pain
- B. Numbness in the toes
- C. Clear urine output
- D. Stable vital signs
Correct Answer: B
Rationale: Numbness in the toes may indicate nerve compression or damage, a potential complication requiring further evaluation.
The 28-year-old client is on the rehabilitation unit post spinal cord injury at level T10. Which collaborative team members should participate with the nurse at the case conference? Select all that apply.
- A. Occupational Therapist (OT).
- B. Physical therapist (PT).
- C. Registered dietitian (RD).
- D. Rehabilitation physician.
- E. Social Worker (SW).
- F. Patient care tech (PCT).
Correct Answer: A,B,D,E
Rationale: OT (A) and PT (B) address functional and mobility needs, the physician (D) oversees medical care, and the social worker (E) coordinates resources. Dietitian (C) and PCT (F) are less critical for case conferences.