A nurse is caring for a 15-year-old adolescent who has cellulitis of the left lower calf.

Exhibits

The nurse is assessing the adolescent 24 hr after the initial visit. How should the nurse interpret the findings?

For each finding, click to specify whether the finding is an indication of potential improvement or an indication of potential worsening condition. There must be at least 1 selection in every row. There does not need to be a selection in every column.

Rationale for correct choices:

• Seizures: Clients with meningitis are at risk for seizures due to meningeal irritation, high fever, and increased intracranial pressure. Neurological complications arise as the infection spreads within the central nervous system, disrupting electrical activity in the brain.

• Level of consciousness: The adolescent is lethargic, drowsy, and irritable when aroused, which reflects altered neurological status. This finding indicates cerebral involvement, which increases the likelihood of seizure activity as the illness progresses.

Rationale for incorrect choices:

• Lyme disease: This condition is caused by tick bites and typically presents with erythema migrans rash, arthralgia, and fatigue, not acute fever, photophobia, or purpuric rash as seen here.

• Pneumonia: Respiratory involvement would present with abnormal breath sounds, cough, or hypoxemia, but this client has clear lung sounds and normal oxygen saturation, making pneumonia unlikely.

• Mononucleosis: This condition usually causes fever, pharyngitis, and lymphadenopathy, but the client’s cervical nodes are normal and their presentation aligns more with meningitis.

• Constipation: Gastrointestinal complications such as constipation are not relevant here since bowel sounds are active, the abdomen is soft, and there are no reports of decreased stooling.

• Abdominal findings: The abdomen is soft, flat, and with normal bowel sounds, which provides no evidence of an abdominal complication linked to meningitis risk.

• Rash: While the purpuric rash supports the diagnosis of meningococcal meningitis, it is not the primary indicator of seizure risk. Neurological status is a stronger predictor of seizure development.

• Cervical lymph nodes: These are normal without edema or tenderness, ruling out lymphatic involvement as a significant concern in this scenario.

• Breath sounds: Breath sounds are clear and equal bilaterally, which excludes a respiratory complication such as pneumonia as the risk factor linked to seizures.

A. "This drug won't decrease the effectiveness of their oral contraceptive medication.": Phenytoin induces hepatic enzymes, which increase the metabolism of oral contraceptives and reduce their effectiveness.

B. "We will need to periodically have their blood drawn to check phenytoin levels.": Phenytoin has a narrow therapeutic index, and blood levels must be monitored to avoid subtherapeutic dosing or toxic effects such as ataxia, confusion, or nystagmus.

C. "This medication may cause their eyes to move quickly back and forth at times.": Nystagmus is a known dose-related adverse effect of phenytoin, especially at higher levels. Recognizing this side effect indicates understanding of possible neurologic manifestations of toxicity.

D. "They will need to take 400 international units (IU) of vitamin E while on this medication.": Vitamin E supplementation is not required for adolescents taking phenytoin. Nutritional support may focus more on maintaining adequate folic acid and vitamin D.

E. "There is nothing we can do to minimize overgrowth of their gum tissue.": Gingival hyperplasia is a common side effect of phenytoin, but it can be minimized with proper oral hygiene such as regular toothbrushing, flossing, and dental visits.