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 C

Explanation

Choice A: have higher sodium content, so they are not the best choices for someone with elevated serum sodium levels.

Choice B: have higher sodium content, so they are not the best choices for someone with elevated serum sodium levels.

Choice C: Skim milk, grapes, and lettuce are good sources of water that can help dilute the sodium level in the blood. Bacon is a high-sodium food, but it is a small portion compared to the other choices and can be balanced by the rest of the meal.

Choice D: this combination contains higher sodium levels, especially canned soup, so it's not the ideal choice.

A. Thready pulse volume. B. Missing pulse. C. Pulse skips beats. D. Light pressure applied to pulse.

Correct Answer is A

Explanation

Choice A: A thready pulse is one that is weak and can be easily obliterated by light pressure.

Choice B: A missing pulse is one that cannot be felt at all.

Choice C: "Pulse skips beats" is a different phenomenon and not an accurate description of the pulse disappearing with light pressure. It is irregular and may indicate a cardiac arrhythmia.

Choice D: Documenting "light pressure applied to pulse" does not convey the specific finding that the pulse disappears with pressure, which is more clinically relevant. It is not a finding, but a method of assessing the pulse.

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

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Naxlex Comprehensive Predictor Exams

A client has a serum sodium level of 155 mEq/L (155 mmol/L). The nurse should encourage the client to make which selection from the lunch menu. Reference Range Sodium [Reference Range: Adult 136 to 145 mEq/L or 136 to 145 mmol/L]

Correct Answer is C

Explanation

The practical nurse (PN) palpates a client's radial pulse and notes that the pulse disappears when light pressure is applied. How should the PN document this finding?

Correct Answer is A

Explanation

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