The nurse is caring for a client with a new diagnosis of epilepsy who is prescribed phenytoin. Which teaching point should the nurse emphasize?

Avoid alcohol consumption

Increase calcium intake

Limit physical activity

Reduce fluid intake

Answer and Explanation

The Correct Answer is A

Choice A reason: Avoiding alcohol is critical with phenytoin, as it increases seizure risk and alters drug metabolism, reducing efficacy or causing toxicity. Alcohol’s CNS depressant effects exacerbate epilepsy, making this the priority teaching point to ensure seizure control and medication safety.

Choice B reason: Increasing calcium intake is unrelated to phenytoin or epilepsy management. While phenytoin may affect bone health long-term, alcohol avoidance is more urgent, as it directly impacts seizure control and drug pharmacokinetics, making it the priority teaching focus.

Choice C reason: Limiting physical activity is unnecessary for epilepsy unless seizures are poorly controlled. Alcohol avoidance is critical, as it lowers the seizure threshold and interferes with phenytoin metabolism, posing immediate risks to seizure control, making it the primary teaching point.

Choice D reason: Reducing fluid intake is irrelevant to phenytoin or epilepsy. Proper hydration supports health, but alcohol avoidance is the priority, as it directly affects seizure risk and phenytoin’s effectiveness, ensuring therapeutic levels and preventing breakthrough seizures in epilepsy management.

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Correct Answer is D

Explanation

Choice A reason: Early ambulation prevents stasis but is contraindicated in acute deep vein thrombosis, as it risks dislodging the clot, causing pulmonary embolism. Leg elevation reduces swelling and promotes venous return, making it the priority intervention to manage acute DVT safely.

Choice B reason: Warm compresses may increase blood flow but are not standard for deep vein thrombosis, as they risk clot dislodgement. Leg elevation reduces edema and venous pressure, improving circulation without mobilizing the clot, making it the preferred intervention for DVT management.

Choice C reason: Restricting fluid intake is inappropriate, as hydration prevents blood viscosity increases that exacerbate deep vein thrombosis. Leg elevation directly reduces swelling and promotes venous return, addressing the primary issue of venous stasis, making it the priority over fluid restriction.

Choice D reason: Elevating the affected leg reduces edema and venous pressure in deep vein thrombosis by promoting venous return to the heart. This decreases clot propagation risk and alleviates pain, making it a key intervention to manage acute DVT effectively and prevent complications.

A. Throat irritation B. Uncontrollable shaking C. Irregular rapid heart rate D. Increased anxiety

Correct Answer is C

Explanation

Choice A reason: Throat irritation is a common albuterol side effect due to its deposition in the oropharynx during inhalation. It is not life-threatening and can be managed with rinsing or spacer use. This does not require immediate intervention compared to cardiovascular effects, as it does not compromise vital organ function.

Choice B reason: Uncontrollable shaking (tremors) is a frequent albuterol side effect, resulting from beta-2 receptor stimulation in skeletal muscles. It is usually transient and benign, not requiring immediate intervention. Monitoring is sufficient unless severe, as it does not pose an acute threat compared to cardiac irregularities.

Choice C reason: An irregular rapid heart rate (tachycardia or arrhythmia) is a serious albuterol side effect, as beta-2 agonists can stimulate beta-1 receptors in the heart, causing cardiovascular instability. This warrants immediate intervention, as it risks cardiac compromise, especially in emphysema patients with compromised respiratory and cardiac reserves.

Choice D reason: Increased anxiety is a possible albuterol side effect due to its stimulatory effects on the central nervous system. While distressing, it is not immediately life-threatening. It requires monitoring but is secondary to cardiovascular complications, which pose a greater acute risk in emphysema patients with wheezing.

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The nurse is caring for a client with a new diagnosis of epilepsy who is prescribed phenytoin. Which teaching point should the nurse emphasize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a history of deep vein thrombosis. Which intervention should the nurse include in the care plan?

Correct Answer is D

Explanation

A client with emphysema is reporting difficulty breathing and exhibiting audible wheezing. The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants immediate intervention by the nurse?

Correct Answer is C

Explanation

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