Nokea
Which instruction should the nurse include for a client taking phenytoin (Dilantin)?
- A. Brush teeth gently to prevent gum hyperplasia.
- B. Avoid grapefruit juice.
- C. Take the medication with milk.
- D. Increase dietary sodium intake.
Correct Answer: A
Rationale: Phenytoin can cause gingival hyperplasia; gentle brushing helps prevent gum complications.
You may also like to solve these questions
For a client with Guillain-Barré syndrome, which complication should the nurse monitor most closely?
- A. Urinary incontinence
- B. Deep vein thrombosis
- C. Hypertension
- D. Hypoglycemia
Correct Answer: B
Rationale: Deep vein thrombosis is a significant risk in Guillain-Barré syndrome due to immobility from muscle weakness.
If the drug is administered every 3 to 4 hours, which nursing action is most appropriate at this time in response to the client's statement?
- A. Administer another dose of the nonopioid analgesic immediately.
- B. Rearrange medication times so that the client receives pain medication hourly.
- C. Consult the physician about ordering an opioid analgesic.
- D. Use a nondrug intervention such as listening to a guided imagery tape.
Correct Answer: D
Rationale: Using a nondrug intervention like guided imagery is appropriate since it's too early for another dose, and it avoids escalating to opioids prematurely.
The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first?
- A. Notify the health-care provider immediately.
- B. Prepare to administer an antihistamine.
- C. Test the drainage for presence of glucose.
- D. Place a 2 x 2 gauze under the nose to collect drainage.
Correct Answer: C
Rationale: Clear nasal drainage post-head injury may indicate cerebrospinal fluid (CSF) leak, confirmed by testing for glucose (C). This is the first step to guide further action. Notifying the provider (A) follows confirmation, antihistamines (B) are irrelevant, and gauze (D) is a secondary measure.
Which client statement indicates understanding of myasthenia gravis management?
- A. I'll take my medication whenever I feel weak.'
- B. I'll avoid crowds to prevent infections.'
- C. I'll exercise vigorously every morning.'
- D. I'll skip doses if I feel better.'
Correct Answer: B
Rationale: Avoiding crowds reduces infection risk, which is critical in myasthenia gravis due to immunosuppressive therapy.
The home health nurse is caring for a 28-year-old client with a T10 SCI who says, 'I can’t do anything. Why am I so worthless?' Which statement by the nurse would be most therapeutic?
- A. This must be very hard for you. You’re feeling worthless?'
- B. You shouldn’t feel worthless—you are still alive.'
- C. Why do you feel worthless? You still have the use of your arms.'
- D. If you attended a work rehab program you wouldn’t feel worthless.'
Correct Answer: A
Rationale: Reflecting the client’s feelings (A) validates their emotions and encourages further discussion, promoting therapeutic communication. Other options dismiss feelings (B), challenge the client inappropriately (C), or assume solutions (D).