Which condition would indicate to the nurse that the patient has a phenytoin (Dilantin) toxicity?
Nystagmus
Strabismus
Blurry vision
Amblyopia
The Correct Answer is A
A. Nystagmus:
Nystagmus is an involuntary, rhythmic movement of the eyes, which can be rapid and jerky. It is a common neurological manifestation of phenytoin toxicity. Patients experiencing phenytoin toxicity may exhibit horizontal or vertical nystagmus, which can be detected upon physical examination.
B. Strabismus:
Strabismus, also known as crossed eyes or squint, refers to a misalignment of the eyes. While strabismus can have various causes, it is not typically associated with phenytoin toxicity. Therefore, it is less likely to indicate phenytoin toxicity compared to nystagmus.
C. Blurry vision:
Blurry vision, or visual disturbances, can occur in patients experiencing phenytoin toxicity. However, it is a non-specific symptom and can be observed in various other conditions as well. Patients with phenytoin toxicity may experience blurry vision, double vision (diplopia), or other visual disturbances due to the effects of the medication on the central nervous system.
D. Amblyopia:
Amblyopia, also known as lazy eye, is a condition characterized by reduced vision in one or both eyes. It is typically associated with visual development during childhood and is not directly related to phenytoin toxicity. Therefore, it is less likely to indicate phenytoin toxicity compared to nystagmus or other neurological manifestations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Toes turning up and spreading:
This description corresponds to the abnormal finding in the Babinski reflex. In a positive Babinski sign, the big toe (hallux) dorsiflexes (turns upward) and the other toes fan out. This response is abnormal in adults but normal in infants up to a certain age.
B. Downward curl of the toes:
This response is typical of the normal plantar reflex, where the toes curl downward (plantar flexion) in response to stimulation of the sole of the foot. It is not indicative of the Babinski reflex.
C. Pain in the big toe:
Pain in the big toe is not a characteristic finding of the Babinski reflex. The Babinski sign is assessed by observing the movement pattern of the toes in response to stimulation, rather than eliciting pain.
D. Big toe bending upward:
The big toe bending upward, or dorsiflexion of the big toe, is a specific component of the positive Babinski sign. However, it is typically accompanied by spreading of the other toes, which is the hallmark feature of the Babinski reflex.
Correct Answer is C
Explanation
A. Extension of the extremities
Extension of the extremities is not consistent with decorticate posturing. Instead, it is more indicative of decerebrate posturing, where both the upper and lower extremities are typically extended.
B. Pronation of the hands
Pronation of the hands is not typically associated with decorticate posturing. In decorticate posturing, the hands are usually flexed with the wrists and fingers pointing towards the body.
C. Plantar flexion of the legs
Plantar flexion of the legs characteristic of decorticate posturing. Decorticate posturing mainly involves plantar flexion of the feet.
D. External rotation of the lower extremities
External rotation of the lower extremities is also not typically associated with decorticate posturing. In decorticate posturing, the lower extremities may exhibit extension or internal rotation, but external rotation is not a characteristic feature.
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