An adult client is admitted to the medical unit due to rectal bleeding after a colonoscopy in which a polyp was biopsied and cauterized. Which Intervention should the nurse do first?

Palpate all peripheral pulses in the extremities.

Encourage cough and deep breathing exercises.

Complete a focused assessment of the abdomen.

Initiate measurement of fluid intake and output.

Answer and Explanation

The Correct Answer is C

A.   While assessing peripheral pulses is important, it's not the priority in this situation. The primary concern is the rectal bleeding.
B.   These exercises are important to prevent postoperative complications like pneumonia, but they are not the immediate priority when a patient is experiencing rectal bleeding.
C.   Assessing the abdomen will help determine the severity of the bleeding, identify any signs of abdominal distention or tenderness, and provide crucial information for further interventions.
D.   Monitoring fluid intake and output is important for any patient, but it's not the initial priority when a patient is actively bleeding.

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

Explanation

A. Vomiting is not a common side effect of phenytoin but could occur in some patients. It’s more likely a
reaction to the medication rather than a frequent side effect.
B. Phenytoin can affect blood coagulation. It may interfere with vitamin K metabolism, which can alter coagulation pathways and increase the risk of bleeding or bruising. Monitoring for signs of bleeding or changes in clotting status is important, particularly in patients on long-term therapy.
C. Visual disturbances, including nystagmus (involuntary eye movements), double vision, or blurred vision, can occur with phenytoin use. This side effect is related to the medication’s impact on the nervous system.
D. Drowsiness is a common side effect of many antiepileptic drugs, including phenytoin. It can affect the client’s alertness and overall level of consciousness, making it important for the nurse to monitor and address any related safety concerns.
E. Aphasia, or difficulty with language and speech, is not a typical side effect of phenytoin. While phenytoin affects the central nervous system, aphasia is not commonly reported with its use.
F. Ataxia, or lack of coordination and unsteady movements, is a known side effect of phenytoin. This occurs due to its effects on the nervous system and can impair motor skills and coordination.

A. Place an indwelling urinary catheter and measure strict Intake and output. B. Initiate bilateral intermittent sequential pneumatic compression devices. C. Administer aspirin to prevent further det formation and platelet dumping. D. Obtain a focused history to determine recent bleeding and use of anticoagulants.

Correct Answer is D

Explanation

A. Monitoring intake and output can be important for overall fluid management, it is not the most urgent intervention for a client presenting with symptoms suggestive of a stroke or other acute neurological event. The immediate concern should be to evaluate and manage the neurological symptoms rather than focusing on urinary output at this stage.
B. Bilateral intermittent sequential pneumatic compression devices are used to prevent deep vein thrombosis (DVT) in immobile patients. This is not directly relevant to the acute neurological symptoms described and does not address the immediate need for evaluating the cause of the sudden headache and facial droop.
C. While aspirin may be used in some cases to prevent further clot formation in patients with certain types of strokes, administering it without a clear diagnosis and without ruling out contraindications could be harmful. The client needs immediate diagnostic evaluation to determine if a stroke or another condition is present before starting any medication like aspirin.
D. Obtaining a focused history is crucial in the context of sudden onset neurological symptoms. This includes assessing for recent bleeding, trauma, or the use of anticoagulants, which can help in diagnosing and managing conditions like stroke. Understanding the client's medication history and any recent bleeding events is important for guiding appropriate treatment and ensuring safe management.

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An adult client is admitted to the medical unit due to rectal bleeding after a colonoscopy in which a polyp was biopsied and cauterized. Which Intervention should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The healthcare provider comes to the bedside following the seizure and prescribes phenytoin. The nurse administers the phenytoin as prescribed. Which possible side effect(s) of phenytoin should the nurse assess for after administration? Select all that apply.

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

Explanation

Correct Answer is D

Explanation

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