What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?

Bladder palpation.

Blood glucose monitoring.

Inspection of the mouth.

Auscultation of breath sounds.

Answer and Explanation

The Correct Answer is C

Choice A: This is not specifically related to the side effects of phenytoin.

Choice B: This is not directly related to the common side effects of phenytoin, which primarily affect the oral cavity.

Choice C: Phenytoin (Dilantin) is known to cause gingival hyperplasia (enlargement of the gums) as a common side effect. The nurse should regularly inspect the client's mouth to monitor for this adverse effect.

Choice D: This is not specifically relevant to monitoring for phenytoin's side effects.

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Correct Answer is A

Explanation

A. Document the findings in the record – A bluish-black discoloration over the lumbosacral area is most likely a Mongolian spot, a benign congenital birthmark commonly seen in infants with darker skin tones. It does not require intervention, only documentation.
B. Report possible child abuse to protective services – Mongolian spots may resemble bruises, but they are not a sign of abuse. Reporting without further assessment is inappropriate.
C. Gently rub the area with skin cream to promote healing – Mongolian spots are not injuries and do not require treatment.
D. Ask the mother about the discoloration – While obtaining history is important, Mongolian spots are well-known benign findings that do not require further clarification from the parent.

A. Inform the client that oatmeal contains gluten. B. Encourage the client to choose decaffeinated coffee. C. Commend the client for selecting fat free milk. D. Advise the client that too much fruit can irritate the colon.

Correct Answer is A

Explanation

Choice A: Oatmeal is often considered a source of gluten, which should be avoided by individuals with celiac disease. The nurse should inform the client that oatmeal may not be suitable for a gluten-free diet.

Choice B: Encouraging the client to choose decaffeinated coffee is a minor consideration and is not the most important action related to celiac disease.

Choice C: Commending the client for selecting fat-free milk is unrelated to the issue of gluten in the oatmeal and is not the most important action.

Choice D: Advising the client about the potential irritant effects of too much fruit on the colon is not directly related to the issue of gluten in the oatmeal and is not the most important action.

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What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During assessment of a 2-month-old infant, the nurse notices a bluish-black discoloration over the lumbosacral area. Which action should the nurse take?

Correct Answer is A

Explanation

A client with celiac disease selects a bowl of oatmeal with fresh fruit and skim milk, grapefruit juice, and coffee from the breakfast menu. Which action is most important for the nurse to implement?

Correct Answer is A

Explanation

When assessing both lower extremities (BLE) of a client who has chronic venous insufficiency, the nurse identifies bilateral stasis dermatitis and an ulcer on the medial surface of the left ankle. To promote effective self-care, which client teaching should the nurse provide?

A male child is being prepared for a computed tomography (CT) scan when he begins to have a tonic clonic seizure. His mother is hysterical and is trying to hold the child down. Which action(s) should the nurse take? (Select all that apply.)

A community health nurse is concerned about the incidence of asthma among preschool aged children in a metropolitan area. Which intervention reflects a primary prevention strategy the nurse might initiate to combat this chronic illness?

The nurse is reviewing a nutrition plan with a client newly diagnosed with hypertension. Which statement by the client indicates an understanding of the Dietary Approaches to Stop Hypertension (DASH) diet?

The practical nurse (PN) is administering a saline enema to a client who was admitted because of a fever of unknown origin and is now constipated. Which techniques should the PN use? (Select all that apply.)

The nurse manager of a community mental health treatment facility is establishing a policy for staff members to follow when administering antipsychotic medications. Which standard is most important for the nurse-manager to include in this policy?