A nurse is reinforcing teaching a client who has a new prescription for phenytoin. The nurse should instruct the client to monitor and report which of the following adverse effects of this medication?
Diarrhea
Wrist pain
Skin rash
Metallic taste
The Correct Answer is C
A. Diarrhea:
Diarrhea is not a common side effect of phenytoin. While gastrointestinal disturbances such as nausea, vomiting, and constipation may occur, diarrhea is less common. Therefore, it is not a primary adverse effect that the nurse should instruct the client to monitor and report.
B. Wrist pain:
Wrist pain is not a common side effect of phenytoin. Side effects related to musculoskeletal issues such as joint pain, muscle weakness, or muscle twitching can occur, but wrist pain specifically is not commonly associated with phenytoin use. Therefore, it is not a primary adverse effect that the nurse should instruct the client to monitor and report.
C. Skin rash:
Skin rash is a potential adverse effect of phenytoin that should be monitored and reported. Phenytoin can cause various skin reactions, including a mild rash or more severe reactions such as Stevens-Johnson syndrome or toxic epidermal necrolysis. Therefore, the nurse should instruct the client to promptly report any signs of skin rash or other skin changes.
D. Metallic taste:
Metallic taste is a common side effect of phenytoin. While it is not usually a serious adverse effect, it can be bothersome for some individuals. Therefore, the nurse should instruct the client to monitor for this side effect and report it if it occurs persistently or becomes bothersome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Adventitious breath sounds:
Adventitious breath sounds refer to abnormal lung sounds heard upon auscultation of the chest. These sounds include crackles (rales), wheezes, rhonchi, and pleural friction rubs. In the context of fluid volume excess, particularly in the acute phase of a cerebrovascular accident (CVA) or stroke, adventitious breath sounds such as crackles are indicative of pulmonary edema. Pulmonary edema occurs when there is an excessive accumulation of fluid in the lungs, impairing gas exchange and leading to symptoms such as shortness of breath and respiratory distress.
B. Weak pulse:
A weak pulse may suggest poor perfusion or decreased cardiac output rather than fluid volume excess. While decreased cardiac output can be a consequence of heart failure, which may be associated with fluid volume excess, a weak pulse is not a direct indicator of fluid overload. In the acute phase of a CVA, a weak pulse may prompt further assessment for other cardiovascular complications or neurogenic shock.
C. Hypotension:
Hypotension, or low blood pressure, is not typically associated with fluid volume excess. Instead, hypotension may indicate hypovolemia, shock, or other underlying cardiovascular conditions. While hypotension can occur secondary to severe heart failure or fluid overload in some cases, it is not a direct indicator of fluid volume excess in the acute phase of a CVA.
D. Poor skin turgor:
Poor skin turgor is a clinical finding associated with dehydration rather than fluid volume excess. In dehydration, the skin loses its elasticity and becomes less resilient when pinched. In contrast, fluid volume excess is characterized by edema, which may manifest as pitting or non-pitting edema, rather than poor skin turgor. However, in fluid volume excess, the skin may appear stretched or taut due to the accumulation of fluid in the interstitial spaces.
Correct Answer is ["0.6"]
Explanation
To calculate the dose of diazepam in mL, the nurse should use the formula:
Dose (mL) = Desired dose (mg) / Available dose (mg/mL)
Plugging in the values from the question, we get:
Dose (mL) = 3 mg / 5 mg/mL
Simplifying, we get:
Dose (mL) = 0.6 mL
Therefore, the nurse should administer 0.6 mL of diazepam IM.
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