A nurse is caring for a client who is taking phenytoin and has a seizure disorder. For which of the following adverse effects should the nurse monitor the client?

Hypoglycemia

Gingival hyperplasia

Ringing of the ears

Elevated blood pressure

Answer and Explanation

The Correct Answer is B

A. Hypoglycemia: Phenytoin does not typically lower blood glucose levels, so hypoglycemia is not a common adverse effect. Blood glucose monitoring is not routinely required for clients on phenytoin unless they have an underlying metabolic disorder.

B. Gingival hyperplasia: Phenytoin can cause overgrowth of gum tissue, particularly with long-term use, leading to swelling, bleeding, and discomfort. Good oral hygiene and regular dental care are important to manage and prevent progression. This is a well-documented and common adverse effect of the medication.

C. Ringing of the ears: Tinnitus is more commonly associated with high doses of certain antibiotics or salicylates, not phenytoin. Although phenytoin toxicity can cause neurologic symptoms, ringing in the ears is not a primary concern for routine monitoring.

D. Elevated blood pressure: Phenytoin does not directly raise blood pressure. Blood pressure monitoring is still important for overall health, but hypertension is not an expected adverse effect of this anticonvulsant medication.

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Correct Answer is A

Explanation

A. Limit instructions to two steps at a time: Clients with Alzheimer's disease have impaired short-term memory and difficulty processing complex information. Providing simple, stepwise instructions improves comprehension and reduces frustration during care activities.

B. Vary the staff providing care for the client: Frequent changes in caregivers can increase confusion and anxiety in clients with Alzheimer's disease. Consistent staffing promotes a sense of familiarity, security, and trust, which supports overall well-being.

C. Encourage socialization as a distractor when the client becomes agitated: While social interaction can be beneficial, forcing socialization during agitation may worsen confusion or stress. Interventions should focus on calming strategies and meeting the client’s immediate needs.

D. Encourage independence in ADLS: Promoting independence is important but must be balanced with the client’s cognitive and functional abilities. Overemphasis on independence without support may lead to frustration or safety risks during daily activities.

A. Place the client on NPO status B. Place the client's right leg in a dependent position C. Open the splint D. Obtain a urinalysis

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

• Place the client on NPO status: Clients with compartment syndrome often require emergent surgical intervention, such as a fasciotomy. Keeping the client NPO ensures safety in case anesthesia is needed for immediate surgery.

• Obtain a urinalysis: Compartment syndrome can lead to rhabdomyolysis and myoglobinuria, which can damage the kidneys. A urinalysis helps detect myoglobin in the urine and guides interventions to prevent acute kidney injury.

• Place the client's right leg in a dependent position: Lowering the affected limb increases pressure within the compartment, worsening ischemia and tissue damage. The limb should be kept at heart level or slightly elevated to optimize perfusion without increasing pressure.

• Open the splint: Removing the splint or cast without surgical or provider guidance can worsen tissue swelling and damage, as well as increase the risk of further injury. Immediate provider assessment is required before altering immobilization.

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A nurse is caring for a client who is taking phenytoin and has a seizure disorder. For which of the following adverse effects should the nurse monitor the client?

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Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

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