A client with a seizure disorder is seen at the clinic for a follow-up visit and a prescription renewal for phenytoin. Which assessment finding warrants immediate intervention by the nurse?

Blood pressure 100/78 mm Hg.

Double vision.

Puffy, bleeding gums.

Chronic insomnia.

Answer and Explanation

The Correct Answer is B

Choice A reason: This is not an assessment finding that warrants immediate intervention by the nurse. Blood pressure 100/78 mm Hg is within the normal range for an adult, and it does not indicate any adverse effect of phenytoin. The nurse should monitor the blood pressure for any changes, but it is not a priority.

Choice B reason: This is an assessment finding that warrants immediate intervention by the nurse. Double vision, or diplopia, is a sign of phenytoin toxicity, which can occur due to overdose, drug interactions, or impaired metabolism. Double vision can impair the client's vision, balance, and coordination, and increase the risk of falls and injuries. The nurse should stop the phenytoin infusion, if applicable, and notify the healthcare provider. The nurse should also check the serum phenytoin level and other vital signs, and prepare to administer an antidote, such as fosphenytoin, if indicated.

Choice C reason: This is not an assessment finding that warrants immediate intervention by the nurse. Puffy, bleeding gums are a common side effect of phenytoin, which can cause gingival hyperplasia, or overgrowth of the gum tissue. Puffy, bleeding gums are not life-threatening, but they can affect the client's oral hygiene and appearance. The nurse should instruct the client to brush and floss the teeth regularly, and to visit a dentist for dental care.

Choice D reason: This is not an assessment finding that warrants immediate intervention by the nurse. Chronic insomnia is not a common or serious side effect of phenytoin, which is an anticonvulsant that can have sedative effects. Chronic insomnia may be caused by other factors, such as stress, pain, or caffeine intake. The nurse should assess the client's sleep pattern and quality, and provide education and counseling on sleep hygiene and relaxation techniques.

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Correct Answer is C

Explanation

Choice A reason: Administering both prescribed medications as scheduled is not the appropriate action in this situation. The client's total calcium level is above the normal range of 9 to 10.5 mg/dL (2.25 to 2.62 mmol/L), indicating hypercalcemia. Hypercalcemia is a serious condition that can cause nausea, vomiting, constipation, confusion, kidney stones, and cardiac arrhythmias. Giving more calcitriol and calcium carbonate would worsen the client's condition and increase the risk of complications.

Choice B reason: Holding the calcium carbonate, but administering the calcitriol as scheduled is not the appropriate action in this situation. Calcium carbonate is a supplement that provides extra calcium to the body. Calcitriol is a synthetic form of vitamin D that helps the body absorb calcium from the intestines and kidneys. Both medications can increase the blood calcium level and cause hypercalcemia. The nurse should not give either medication without consulting the healthcare provider.

Choice C reason: Holding both medications until contacting the healthcare provider is the best action in this situation. The nurse should recognize that the client's total calcium level is dangerously high and report it to the healthcare provider as soon as possible. The healthcare provider may order to stop or adjust the doses of calcitriol and calcium carbonate, and prescribe other treatments to lower the blood calcium level, such as intravenous fluids, diuretics, or bisphosphonates.

Choice D reason: Holding the calcitriol, but administering the calcium carbonate as scheduled is not the appropriate action in this situation. Calcium carbonate is a supplement that provides extra calcium to the body. Giving more calcium carbonate to a client with hypercalcemia would increase the blood calcium level even more and cause more harm. The nurse should not give any medication that can raise the blood calcium level without consulting the healthcare provider.

A. Perform a bladder scan. B. Assess urine output. C. Measure blood pressure. D. Monitor daily weights.

Correct Answer is C

Explanation

Choice A reason: Performing a bladder scan is not the most relevant intervention for monitoring an adverse reaction to tamsulosin. A bladder scan is a non-invasive test that measures the amount of urine in the bladder. It can be used to assess urinary retention, which is a common symptom of benign prostatic hyperplasia. Tamsulosin is a medication that relaxes the smooth muscle of the prostate and bladder neck, which can improve urine flow and reduce urinary retention. However, a bladder scan does not indicate how the medication is affecting the client's blood pressure, which is a more serious concern.

Choice B reason: Assessing urine output is not the most relevant intervention for monitoring an adverse reaction to tamsulosin. Urine output is the amount of urine produced by the kidneys and excreted by the bladder. It can be used to evaluate the client's fluid balance and kidney function. Tamsulosin is a medication that can improve urine flow and reduce urinary retention in clients with benign prostatic hyperplasia. However, urine output does not indicate how the medication is affecting the client's blood pressure, which is a more serious concern.

Choice C reason: Measuring blood pressure is the most relevant intervention for monitoring an adverse reaction to tamsulosin. Blood pressure is the force of blood against the walls of the arteries. It can be affected by various factors, such as heart rate, blood volume, and vascular resistance. Tamsulosin is a medication that belongs to the class of alpha-blockers, which can lower blood pressure by dilating the blood vessels. This can cause side effects such as dizziness, fainting, and orthostatic hypotension, which is a sudden drop in blood pressure when changing positions. The nurse should measure the client's blood pressure regularly and report any abnormal findings to the healthcare provider.

Choice D reason: Monitoring daily weights is not the most relevant intervention for monitoring an adverse reaction to tamsulosin. Daily weights are a measure of the client's body mass, which can reflect changes in fluid status and nutritional intake. Tamsulosin is a medication that can improve urine flow and reduce urinary retention in clients with benign prostatic hyperplasia. However, daily weights do not indicate how the medication is affecting the client's blood pressure, which is a more serious concern.

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A client with a seizure disorder is seen at the clinic for a follow-up visit and a prescription renewal for phenytoin. Which assessment finding warrants immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After administering oral doses of calcitriol and calcium carbonate to a client with hypoparathyroidism, the nurse notes that the client's total calcium level is 14 mg/dL (3.5 mmol/L). Which action should the nurse implement?

Correct Answer is C

Explanation

A client with benign prostatic hyperplasia receives a new prescription of tamsulosin. Which intervention should the nurse perform to monitor for an adverse reaction?

Correct Answer is C

Explanation

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