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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: A high protein diet is generally not recommended for clients with glomerulonephritis, as it can put additional strain on the kidneys.
Choice B: In glomerulonephritis, there is impaired kidney function, and sodium and fluid restrictions are often necessary to manage fluid balance and blood pressure.
Therefore, the nurse should instruct the client to restrict sodium-rich foods and excessive oral fluids.
Choice C: A low carbohydrate diet with low glycemic index foods is not a specific dietary recommendation for managing glomerulonephritis.
Choice D: Dietary potassium restriction may vary depending on the individual client's potassium levels and needs, so it should be determined by the healthcare provider. It is not a blanket recommendation for all clients with glomerulonephritis.
Correct Answer is C
Explanation
A. A minimally furnished room may be beneficial for safety, but it is not the primary consideration for room assignment.
B. A room with multiple roommates may increase stimulation, which can worsen manic symptoms.
C. A quiet room away from the nurse's station helps reduce environmental stimuli, which can help manage the client's elated state.
D. A bright-colored room near the recreation area may increase sensory stimulation, potentially worsening manic symptoms.
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