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

Explanation

A. While neutrophils are involved in the immune response and wound healing, they are more indicative of an acute infection. An increased wound size suggests a worsening chronic condition rather than an acute infection.
B. C-reactive protein (CRP) is a sensitive marker of inflammation. An increase in CRP often accompanies worsening inflammation, such as an increase in wound size. Evaluating CRP levels would provide valuable information about the overall inflammatory state of the client.
C. Platelets are involved in blood clotting and wound healing, but they are not directly related to the overall inflammatory process or wound size.
D. These electrolytes are important for overall health, but they are not directly related to wound healing or inflammation.

A. Encourage deep breathing and coughing exercises. B. Teach a family member to administer eye drops. C. Provide an eye shield to be worn while sleeping D. Obtain vital signs every 2 hours during hospitalization.

Correct Answer is C

Explanation

A. Deep breathing and coughing are important for general postoperative care but they are not specifically indicated for immediate postoperative cataract surgery. These exercises can increase intraocular pressure and potentially disrupt the healing process.
B. While it's important to educate caregivers about medication administration, this is not the priority in the immediate postoperative period. The patient should be stable and comfortable before teaching begins.
C. An eye shield is crucial to protect the operated eye from accidental injury during sleep. It prevents rubbing and potential complications.
D. Monitoring vital signs is essential for postoperative care. However, the frequency of every 2 hours is excessive for cataract surgery. Vital signs can be monitored less frequently, depending on the patient's condition.

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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

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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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.

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.