The nurse reviews laboratory results for a client with a traumatic brain injury prescribed phenytoin.
The nurse notes the phenytoin level is 32 mg/dL (normal range 10-20 mg/dL). Which findings should the nurse anticipate? Select all that apply.
Nystagmus.
Hypoglycemia.
Ataxia.
Vertigo.
High platelet level.
Correct Answer : A,C,D
This case involves phenytoin toxicity resulting from a level exceeding the therapeutic range of 10 to 20 mg/dL. Knowledge of central nervous system effects, pharmacokinetics, and toxicological manifestations of anticonvulsants is necessary to identify appropriate neurological assessment findings.
Choice A rationale
Nystagmus, or involuntary eye movement, is a classic sign of phenytoin toxicity as levels rise above 20 mg/dL. It results from the drug's effect on the cerebellum and vestibular system, disrupting normal extraocular muscle coordination and balance.
Choice B rationale
Phenytoin typically causes hyperglycemia rather than hypoglycemia because it inhibits insulin secretion. A serum level of 32 mg/dL would not be expected to lower blood glucose; monitoring for elevated glucose levels is more appropriate in toxicity.
Choice C rationale
Ataxia involves uncoordinated muscle movements and gait instability, frequently occurring when phenytoin levels exceed therapeutic limits. The drug affects cerebellar function, leading to significant motor impairment and increasing the client's risk for falls and physical injury.
Choice D rationale
Vertigo or dizziness is a common central nervous system side effect of high phenytoin concentrations. As the drug reaches toxic levels like 32 mg/dL, it interferes with vestibular signaling, causing the sensation of spinning or loss of balance.
Choice E rationale
Phenytoin toxicity is more likely to cause blood dyscrasias like leukopenia or thrombocytopenia rather than a high platelet level. Normal platelet counts are 150,000 to 400,000 cells/mm; high levels are not a recognized manifestation of phenytoin overdose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Determining priority assessments in hospice care requires applying Maslow's hierarchy and the nursing process. Understanding the medical diagnosis is foundational for anticipating physical needs, managing symptoms, and ensuring safety, which precedes addressing psychosocial, spiritual, or financial concerns during the initial admission phase.
Choice A rationale
Identifying the medical diagnosis is essential for clinical decision making and symptom management. It allows the nurse to anticipate complications, understand prognosis, and provide appropriate pharmacological interventions to ensure comfort, which is the primary goal of hospice.
Choice B rationale
While financial stability affects long term care planning, it is not the immediate clinical priority upon admission. Basic physiological needs and medical stability must be addressed before the nurse evaluates the client's insurance coverage or socioeconomic status.
Choice C rationale
Spiritual assessment is a core component of holistic hospice care, yet it follows physical stabilization. The nurse must first ensure the client is not in acute physical distress before exploring religious beliefs or existential concerns.
Choice D rationale
Assessing the support system is vital for planning home care and caregiver respite. However, without understanding the medical condition first, the nurse cannot accurately determine the level of support or specific skills the family needs.
Correct Answer is ["13376"]
Explanation
This scenario requires calculating fluid resuscitation requirements for a burn patient. Knowledge of the Parkland formula is necessary to determine the total volume of isotonic crystalloids required based on weight and the percentage of total body surface area burned.
Step 1 is 4 mL × 88 kg × 38 percent.
Step 2 is 352 × 38.
Step 3 is 13376 mL.
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