A nurse is evaluating a client who is 70 years old for signs of dehydration.

Which of the following findings should the nurse expect?

The correct answer is B, C, and E.

Phenytoin (Dilantin) is an anticonvulsant medication that is used to control seizures.

It can have several side effects, some of which are serious and require medical attention.

Here are some explanations for each choice:.

A. Avoid drinking grapefruit juice while taking this medication.

This iswrongbecause grapefruit juice does not interact with phenytoin.However, grapefruit juice can affect the levels of other medications, such as statins, calcium channel blockers, and some antidepressants.

B. Brush your teeth gently with a soft-bristled toothbrush.This isrightbecause phenytoin can causegingival hyperplasia, which is an overgrowth of the gums that can lead to bleeding, infection, and difficulty chewing.

To prevent this, patients should practice good oral hygiene, avoid alcohol and tobacco, and see a dentist regularly.

A. Avoid drinking grapefruit juice while taking this medication B.

Brush your teeth gently with a soft-bristled toothbrush C.

Wear a medical alert bracelet or necklace at all times D.

Stop taking this medication if you develop a rash or fever E.

Have your blood levels checked regularly as directed by your provider

The correct answer isA, B, and C.

These interventions are appropriate for a client who has impaired tactile sensation due to aging.

• Ais correct because monitoring the client’s skin for signs of injury or infection can help prevent complications such as pressure ulcers, burns, or infections that might go unnoticed by the client due to reduced sensitivity.

• Bis correct because teaching the client to avoid exposure to extreme temperatures can protect the client from thermal injuries such as frostbite or heatstroke that might not be felt by the client due to diminished thermoreception.

• Cis correct because encouraging the client to use assistive devices for mobility and balance can enhance the client’s safety and independence by compensating for the loss of proprioception and kinesthesia that might impair the client’s coordination and stability.

• Dis wrong because providing the client with sensory stimulation such as massage or music is not directly related to impaired tactile sensation due to aging.While sensory stimulation might have other benefits for the client’s well-being, it does not address the specific problem of reduced touch perception.

• Eis wrong because advising the client to wear loose-fitting clothing and shoes is not helpful for a client who has impaired tactile sensation due to aging.In fact, loose-fitting clothing and shoes might increase the risk of falls or injuries by creating friction or slipping off the client’s body.

Normal ranges for tactile sensation vary depending on the type of stimulus, the location of the skin, and the method of testing.

However, some general guidelines are:.

• Vibration sense: normal threshold is less than 10 μm at 30 Hz on the fingertip.

• Temperature sense: normal threshold is less than 1°C difference between two stimuli on the forearm.

• Pressure sense: normal threshold is less than 10 g/mm2 on the fingertip.

• Pain sense: normal threshold is less than 0.5 g/mm2 on the fingertip.