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.

Vomiting

Altered blood coagulation

Visual disturbances

Drowsiness

Aphasia

Ataxia

Answer and Explanation

Correct Answer : B,C,D,F

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.

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

Explanation

A. Pneumonia is an acute infection that causes inflammation in the lungs. While it can lead to significant respiratory symptoms and changes, it is not typically associated with clubbed nails. Clubbing usually develops over a longer period and is more common in chronic conditions.
B. Clubbing of the nails is often associated with lung cancer, particularly with bronchogenic carcinoma. The exact mechanism is not entirely clear, but it may relate to the presence of a malignancy causing systemic changes or the release of growth factors that affect nail tissue.
C. The flu is a viral respiratory infection that is usually acute and self-limiting. Clubbed nails are not a common manifestation of influenza. Clubbing is more associated with chronic respiratory and systemic conditions rather than acute viral infections.
D. COPD, which includes emphysema and chronic bronchitis, is not commonly associated with clubbing.

E. Chronic bronchitis, a type of COPD characterized by persistent cough and sputum production, may lead to clubbed nails in some cases. The chronic hypoxemia and long-term inflammation can contribute to this nail change, although it is less commonly seen than with other conditions.

A. Initiate a referral for ophthalmic evaluation as soon as possible. B. Advise the client to maintain normal activities, but avoid contact sports until the spots resolve C. Instruct the client to rest, and report to the emergency department if eye pain develops. D. Tell the client to apply warm, moist compresses and notify the healthcare provider if there is no improvement.

Correct Answer is A

Explanation

A. The sudden onset of flashing lights and floaters can be a symptom of a detached retina, a serious eye condition that requires immediate medical attention.
B. This is incorrect. The client should not engage in any activities until the condition is evaluated by a healthcare professional.
C. While rest might seem appropriate, the client should seek immediate medical attention due to the potential seriousness of the symptoms.
D. Warm compresses are not indicated for this condition, and the client should seek immediate medical attention.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse reviews client data. Select the 3 possible conditions that could have the clinical manifestation of clubbed nails for this client.

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

Explanation

A middle-aged client reports a sudden onset of seeing flashing lights and floating spots. Which is the best nursing action?

Correct Answer is A

Explanation

After being transferred from the emergency department to a medical unit, a client vomits into an emesis basin. The nurse observes the emesis as seen in the picture. Which assessment should the nurse complete first?

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Exhibits The nurse provides education about seizures to the client and asks the client to explain what he understands about his condition. For each statement click to specify if the client demonstrates an understanding or no understanding. Each row must have one option selected.

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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.