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 ["B","D"]

Explanation

A. Furnish restraints at the bedside: Restraints are not indicated for clients with seizure disorders. In fact, restraints can increase the risk of injury during a seizure and should be avoided.

B. Keep an oxygen setup at the bedside: Oxygen may be necessary to support the client's respiratory function during and after a seizure. Having an oxygen setup readily available can ensure prompt administration if needed.

C. Place the bed in the lowest position: Lowering the bed can help prevent injury if the client
falls out of bed during a seizure. However, it is not always feasible or necessary to lower the bed to the lowest position, especially if the client has mobility limitations or other considerations.

D. Provide a suction setup at the bedside: Suctioning may be necessary to clear the airway and prevent aspiration if the client experiences excessive oral secretions or vomiting during or after a seizure.

E. Elevate the side rails near the head when the client is in bed: Elevating the side rails near the head can help prevent injury if the client thrashes or moves unpredictably during a seizure. However, it is essential to ensure that the client's head and neck remain adequately supported and that the side rails do not restrict access to the client during a seizure.

A. "You may be able to prevent Bell's palsy by doing facial exercises regularly." B. "Medications to treat Bell's palsy work only if started before paralysis onset." C. "Call the doctor if you experience pain or develop herpes lesions near the ear." D. "Prophylactic treatment of herpes with antiviral agents prevents Bell's palsy."

Correct Answer is C

Explanation

A. "You may be able to prevent Bell's palsy by doing facial exercises regularly." Regular facial exercises have not been proven to prevent Bell's palsy. In fact, excessive facial exercises could potentially exacerbate symptoms in some cases.

B. "Medications to treat Bell's palsy work only if started before paralysis onset." While early treatment with antiviral medications may be beneficial in some cases, it is not accurate to say that medications only work if started before paralysis onset. Treatment can still be effective even after the onset of symptoms, although it may not be as effective as when started early.

C. "Call the doctor if you experience pain or develop herpes lesions near the ear." This is important information because Bell's palsy has been associated with reactivation of the herpes simplex virus. Pain or the development of herpes lesions near the ear could indicate impending or active Bell's palsy, and prompt medical evaluation is necessary.

D. "Prophylactic treatment of herpes with antiviral agents prevents Bell's palsy." While antiviral medications can reduce the risk of herpes simplex virus reactivation, there is no guarantee that prophylactic treatment will prevent Bell's palsy. However, prompt treatment of herpes outbreaks may help reduce the risk.

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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 nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include? (Select all that apply.)

Correct Answer is ["B","D"]

Explanation

The nurse identifies a patient with type 1 diabetes and a history of herpes simplex infection as being at risk for Bell's palsy. Which information should the nurse include in teaching the patient?

Correct Answer is C

Explanation

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