A patient has been taking phenytoin (Dilantin) for 2 years. Which action should the nurse take when evaluating possible adverse effects of the medication?

Auscultate the bowel sounds.

Inspect the oral mucosa

Check pupil reaction to light.

Listen to the lung sounds.

Answer and Explanation

The Correct Answer is B

A. Auscultate the bowel sounds: While gastrointestinal side effects such as nausea or
constipation can occur with phenytoin, auscultating bowel sounds is not a specific assessment related to its adverse effects.

B. Inspect the oral mucosa: Phenytoin is associated with gingival hyperplasia, a condition characterized by overgrowth of gum tissue. Therefore, inspecting the oral mucosa for signs of gum enlargement or other oral changes is important for evaluating adverse effects of phenytoin.

C. Check pupil reaction to light: Phenytoin does not typically affect pupil reaction to light. This assessment is more relevant for medications that act on the central nervous system or conditions affecting cranial nerve function.

D. Listen to the lung sounds: Phenytoin is not typically associated with respiratory side effects. Assessing lung sounds may be relevant in certain clinical situations, but it is not a specific assessment related to phenytoin adverse effects.

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Correct Answer is ["A","E","F"]

Explanation

A. Suction Tubing: This equipment is necessary for clearing the patient's airway in case of any secretions or vomitus that could obstruct breathing following a seizure episode.

B. Nasogastric Tube: While nasogastric tubes may be necessary in some medical conditions, they are not typically indicated following treatment for status epilepticus unless there are specific concerns related to the patient's condition that require gastric decompression or feeding.

C. Urinary Catheter: While urinary catheters may be used in some cases, they are not routinely required following treatment for status epilepticus unless there are specific concerns about urinary retention or monitoring of urine output.

D. Tongue Blade: Tongue blades are not typically necessary following treatment for status epilepticus. They may pose a risk of injury to the patient if used unnecessarily.

E. Oxygen Mask: Oxygen masks are essential for providing supplemental oxygen to the patient, especially if there are concerns about hypoxia following a seizure episode.

F. Side Rail Pad: Side rail pads are important for preventing injury to the patient during postictal confusion or agitation. They help to protect the patient from accidentally falling out of bed or injuring themselves against the bed rails.

A. Place the client with the head reclined back to facilitate swallowing. B. Place food in the affected side of the mouth. C. Encourage the client to take small bites. D. Encourage brief exercise before meals to promote appetite.

Correct Answer is C

Explanation

A. Placing the client with the head reclined back can increase the risk of aspiration and is not recommended.
B. Placing food in the affected side of the mouth could lead to choking, as the client may have reduced sensation or control on that side.
C. Encouraging the client to take small bites can help prevent choking and make swallowing easier.
D. While exercise might promote appetite, it is not directly related to feeding safety and should be discussed separately from swallowing instructions.

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A patient has been taking phenytoin (Dilantin) for 2 years. Which action should the nurse take when evaluating possible adverse effects of the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room? (Select all that apply.)

Correct Answer is ["A","E","F"]

Explanation

A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?

Correct Answer is C

Explanation

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)

A patient has been taking phenytoin (Dilantin) for 2 years. Which action should the nurse take when evaluating possible adverse effects of the medication?

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