Nokea
The nurse is reviewing laboratory data for a client taking prescribed phenytoin. The client's phenytoin level is 12 mcg/mL (10-20 mcg/mL). Which action should the nurse take next?
- A. Evaluate the client for non-adherence
- B. Instruct the client to skip the next scheduled dose
- C. Assess the client for phenytoin toxicity
- D. Document the result as within normal limits
Correct Answer: D
Rationale: A phenytoin level of 12 mcg/mL is within the therapeutic range (10-20 mcg/mL), so the nurse should document the result as normal. Non-adherence, skipping doses, or toxicity assessment are not indicated.
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The nurse is reviewing laboratory data for a client with epilepsy taking prescribed valproic acid (VPA). The client's VPA level is 40 mcg/mL (50-125 mcg/mL). Based on the laboratory data, the nurse should
- A. Evaluate the client for non-adherence
- B. Instruct the client to skip the next scheduled dose
- C. Assess the client for VPA toxicity
- D. Document the result as within normal limits
Correct Answer: A
Rationale: A VPA level of 40 mcg/mL is below the therapeutic range (50-125 mcg/mL), suggesting possible non-adherence to the prescribed regimen. Skipping a dose is inappropriate, toxicity is unlikely with a low level, and the result is not within normal limits.
The nurse is caring for a client receiving prescribed sumatriptan. Which client report would indicate that the client is experiencing an adverse response?
- A. Nervousness
- B. Warm sensation
- C. Angina
- D. Tingling sensation
Correct Answer: C
Rationale: Sumatriptan, a triptan used for migraines, can cause coronary vasospasm, leading to angina (chest pain), a serious adverse effect requiring immediate attention. Nervousness, warm sensation, and tingling are common, less severe side effects.
The nurse is caring for a client diagnosed with epilepsy. The nurse should anticipate a prescription for which of the following medications? Select all that apply.
- A. Topiramate
- B. Risperidone
- C. Prazosin
- D. Hydroxyzine
- E. Lorazepam
Correct Answer: A,E
Rationale: Topiramate and lorazepam are used for epilepsy (topiramate for seizure prevention, lorazepam for acute seizures). Risperidone, prazosin, and hydroxyzine are not indicated for epilepsy.
The nurse is assessing a client with Guillain-Barré syndrome. Which of the following would be an expected finding?
- A. Hyperreflexia
- B. Perseveration
- C. Dystonia
- D. Paresthesia
Correct Answer: D
Rationale: Paresthesia (tingling/numbness) is common in Guillain-Barré syndrome due to peripheral nerve demyelination.
The nurse assesses a client with damage to cranial nerve III. Which finding would be expected?
- A. Ptosis
- B. Anosmia
- C. Uvula deviation
- D. Asymmetric facial movement
Correct Answer: A
Rationale: Cranial nerve III (oculomotor) damage causes ptosis due to impaired eyelid elevation.