Chp. 19 - Anticonvulsants
A female patient who takes phenytoin for epilepsy becomes pregnant. The nurse will notify the patient's provider and will anticipate that the provider will take which action? a. Add valproic acid (Depakote) for improved seizure control. b. Change the medication to phenobarbital (Luminal). c. Closely monitor this patient's serum phenytoin levels. d. Discontinue all anticonvulsant medications.
ANS: B Phenytoin has serious teratogenic effects, so women who are pregnant should not take it. Phenobarbital is typically used because possible teratogenic effects are less pronounced. Teratogenicity increases with multiple anticonvulsants.
A patient who has epilepsy will begin an anticonvulsant medication. The patient asks the nurse how long the medication will be necessary. How will the nurse respond? a. "The medication is usually taken for a lifetime." b. "The medication will be given until you are seizure-free." c. "You will need to take the medication for 3 to 5 years." d. "You will take the medication as needed for seizure activity."
ANS: A Anticonvulsants are given to prevent seizures and are usually taken throughout the patient's lifetime. Stopping the medication will lead to recurrence of seizures in most patients. Some patients may attempt to stop taking the medications after 3 to 5 years of no seizure activity. Anticonvulsants are not given as needed.
A patient has recently begun taking phenytoin (Dilantin) for a seizure disorder. The nurse notes a reddish-brown color to the patient's urine. Which action will the nurse take? a. Ask the provider to order a serum drug level. b. Reassure the patient that this is a harmless side effect. c. Report possible thrombocytopenia to the provider. d. Request an order for a urinalysis and creatinine clearance.
ANS: B Reddish-brown urine is a harmless side effect of phenytoin. The nurse should reassure the patient. It is not necessary to order a serum drug level or renal function studies. It is not a symptom of thrombocytopenia.
A patient has been started on an anticonvulsant for a seizure disorder and asks how long he will need to take the medication. What is the nurses best response? a. you will need to take an anticonvulsant of some type for your lifetime b. this medication should be taken until you haven't had a seizure for a month c. seizures are unpredictable and so is the duration of the treatment d. ou will only need to take it for a short period of time because anticonvulsants will cure the seizure disorder
a
A patient presents to the ER in status epilepticus. Which medication would the nurse anticipate to be ordered first: a. diazepam (Valium) b. Midazolam (Versed) c. Propofol (Diprivan) d. Phenobarbital
a
The nurse is preparing discharge teaching for a patient who has been started on phenytoin for a seizure disorder. What info about side effects of this medicine should the nurse provide to the patient and his family? a. there may be a green discoloration of the pt urine b. it is best to use a hard bristle toothbrush for dental care c. nosebleeds and sore throats should be reported to the health care provider d. the pt should get up slowly to prevent fainting
c
Which anticonvulsant may also be used as prophylaxis for migraine headaches? a. diazepam (Valium) b. Phenytoin (Dilantin) c. Valproic acid (Depakote) d. Clorazepate (Tranxene)
c
A patient who takes phenytoin reports regular alcohol consumption. The nurse might expect a serum phenytoin level in this patient to be in which range? a. 5 to 10 mcg/mL b. 10 to 20 mcg/mL c. 20 to 30 mcg/mL d. 30 to 50 mcg/mL
ANS: A Chronic ingestion of alcohol increases hydantoin metabolism, which would decrease serum drug levels. The therapeutic range is 10 to 20 mcg/mL, so a level lower than this may be expected in patients who consume alcohol regularly.
An intubated child is brought to the emergency department while having a seizure that has been progressing for 20 minutes. Which drug will the nurse anticipate administering to this patient? a. Diazepam (Valium) b. Phenobarbital (Luminal) c. Phenytoin (Dilantin) d. Valproic acid (Depakote)
ANS: A Diazepam is given to patients in status epilepticus and is administered IV. The other anticonvulsant medications do not have a rapid onset and are not used for emergencies.
The nurse is preparing to administer phenytoin (Dilantin) to a patient who has a seizure disorder. The patient appears drowsy, and the nurse notes that the last random serum drug level was 18 mcg/mL. What action will the nurse take? a. Administer the dose since the patient is not toxic. b. Contact the provider to discuss decreasing the phenytoin dose. c. Give the drug and monitor closely for adverse effects. d. Report drug toxicity to the providers.
ANS: A Drowsiness is a common side effect of phenytoin and is not cause for alarm. The patient's drug level is normal, since 10-20 mcg/mL is the therapeutic range. The nurse should administer the dose. It is not necessary to decrease the dose or monitor the patient more closely than usual.
The nurse is caring for a patient who has a seizure disorder. The nurse notes that the patient has reddened gums that bleed when oral care is given. The nurse recognizes this finding as a. an adverse effect of the phenytoin. b. a drug interaction with aspirin. c. a symptom of hepatotoxicity. d. a sign of poor self-care.
ANS: A Hydantoins commonly cause gingival hyperplasia, which causes overgrowth of reddened gum tissue that bleeds easily. It is not a sign of a drug interaction or a symptom of hepatotoxicity. It does not indicate a lack of self-care.
The nurse is preparing to administer phenytoin to an 80-year-old patient and notes the following order: IVP phenytoin 50 mg. The nurse will perform which action? a. Administer the undiluted drug through a Y-tube over two minutes. b. Contact the provider to question the route and the dose. c. Dilute the drug in dextrose solution and infuse over 15 to 20 minutes. d. Request an order to administer the drug intramuscularly.
ANS: A Intravenous phenytoin should be administered undiluted through a 3-way stopcock or Y-tubing. In older patients it should be infused at a rate of 25 mcg/min. The dose and the route are appropriate. Phenytoin will precipitate in dextrose solution. Intramuscular injection is very irritating to tissues and is not used.
The nurse is preparing to assist with blood collection on a newly admitted patient who has been taking phenytoin for several years. The provider has ordered a complete blood count and liver function tests. Which other blood test will the nurse discuss with the provider? a. Blood glucose b. Coagulation studies c. Renal function tests d. Serum electrolytes
ANS: A Patients who have taken hydantoins for long periods might have an elevated blood sugar. The nurse should discuss this test with the provider.
A parent of a child who has been taking valproic acid (Depakote) for several years calls the clinic to report a recent recurrence of seizures and states that the child is having 3 or 4 seizures per week. The nurse will perform which action? a. Ask the parent about to describe the child's drug regimen. b. Request an order for a serum valproic acid level. c. Suggest that the parent take the child to the emergency department. d. Tell the parent that the provider will increase the child's dose of Depakote.
ANS: A Questions pertaining to medication adherence are a no-cost, non-invasive way of troubleshooting cause of decreased drug effect. The serum drug level will be assessed next. Children may need changes in doses as they grow. The child is not in status epilepticus so does not need to go to the emergency department. The dose will not be increased until the serum drug level is known.
A patient has recently begun taking carbamazepine (Tegretol) as an adjunct medication to treat refractory seizures. The patient has a serum carbamazepine level of 18 mcg/mL. What action will the nurse take? a. Ask the patient about usual dietary preferences. b. Reassure the patient that this is a therapeutic drug level. c. Report a subtherapeutic drug dose to the provider. d. Suspect a drug-drug interaction.
ANS: A This patient's carbamazepine level is high. When taken with grapefruit juice, an interaction may occur that causes toxicity. The nurse should question the patient about food and fluid preferences. The therapeutic level is 5 to 12 mcg/mL. This is a toxic level, not subtherapeutic.
A parent expresses concern that a 5-year-old child may develop epilepsy because the child experienced a febrile seizure at age 18 months. What will the nurse tell this parent? a. "A child who has had a febrile seizure is considered to have epilepsy." b. "A small percentage of children who have febrile seizures develop epilepsy." c. "I recommend discussing prophylactic anticonvulsant drugs with the provider." d. "Treat fevers aggressively with aspirin and NSAIDs to prevent seizures."
ANS: B Epilepsy develops in 2.5% of children who have one or more febrile seizures. One febrile seizure does not cause a diagnosis of epilepsy. Prophylactic anticonvulsants are given to high-risk patients. Children should not receive aspirin for fever because of the risk of Reye's syndrome.
The nurse is caring for a patient who has been diagnosed with petit mal seizures. The nurse will anticipate teaching this patient about which antiepileptic medication? a. Carbamazepine (Tegretol) b. Ethosuximide (Zarontin) c. Phenobarbital (Luminal) d. Phenytoin (Dilantin)
ANS: B Ethosuximide is used to treat petit mal seizures. The other drugs are not used to treat petit mal seizures.
A 25 year-old female patient will begin taking phenytoin for epilepsy. The patient tells the nurse she is taking oral contraceptives (OCPs). Which response will the nurse give? a. "Continue taking OCPs because phenytoin is not safe during pregnancy." b. "You should use a backup method of contraception along with OCPs." c. "You should stop taking OCPs because of drug-drug interactions with phenytoin." d. "You should take low-dose aspirin while taking these medications to reduce your risk of stroke."
ANS: B Female patients who take oral contraceptives and anticonvulsants should be advised to use a backup method of contraception because of reduced effectiveness of OCPs. Patients should be cautioned to consult with a provider if considering pregnancy because of the teratogenic effects of anticonvulsants. Patients should not stop taking OCPs and do not need to take precautions against stroke.
A patient is diagnosed with epilepsy and asks the nurse what may have caused this condition. The nurse explains that epilepsy is most often a. caused by head trauma. b. idiopathic in origin. c. linked to a stroke. d. related to brain anoxia.
ANS: B Of all seizure cases, 75% are primary, or idiopathic, with no known cause. The remaining are secondary and may be related to head trauma, stroke, or anoxic events.
A pregnant woman who is in labor has a blood pressure of 189/110 mm Hg and exhibits muscle contractions followed by jerking of her arms and legs. The nurse will prepare to administer which medication to this patient? a. Carbamazepine (Tegretol) b. Diazepam (Valium) c. Magnesium sulfate d. Phenobarbital (Luminal)
ANS: C Magnesium sulfate is used to control seizures during eclampsia.
The nurse is performing a health history on a patient who is ordered to begin therapy with valproic acid (Depakote) to treat epilepsy. Which aspect of the patient's medical history will cause the nurse to be concerned? a. Chronic obstructive pulmonary disease b. Gastrointestinal disease c. Liver disease d. Renal disease
ANS: C Valproic acid can elevate liver enzymes. Patients with a history of liver disease should be monitored closely while taking this drug.
A woman who is pregnant is taking an anticonvulsant medication to treat a seizure disorder. The nurse will ensure that the patient takes which dietary supplement toward the end of her pregnancy? a. Folate (folic acid) b. Iron c. Vitamin C d. Vitamin K
ANS: D Anticonvulsants act as inhibitors of vitamin K and can contribute to hemorrhage in infants shortly after birth. Women taking these drugs should receive vitamin K within the last week to 10 days of their pregnancies.
The nurse is providing teaching to the parents of a 5-year-old child who will begin taking phenytoin (Dilantin). What information will the nurse include when teaching these parents about their child's medication? a. "Drug interactions are uncommon with phenytoin." b. "There are very few side effects associated with this drug." c. "The therapeutic range of phenytoin is between 15 and 30 mcg/mL." d. "Your child may need a higher dose than expected."
ANS: D Drug dosage for phenytoin is age-related and children, who have a rapid metabolism, may need higher doses than those used for newborns and adults. Phenytoin has many drug interactions and many side effects. The therapeutic range is 10-20 mcg/mL.
A patient will begin taking the antiepileptic drug ethosuximide (Zarontin) and asks the nurse whether to take the drug with or without food. The nurse will counsel the patient to take this medication a. at bedtime. b. 1 hour before meals. c. 2 hours after meals. d. with meals.
ANS: D Gastric irritation is common with ethosuximide, so patients should be counseled to take it with food. It is given twice daily.
The nurse provides teaching for a patient who will begin taking phenytoin. Which statement by the patient indicates understanding of the teaching? a. "If I develop a rash, I should take diphenhydramine to control the itching." b. "If I experience bleeding gums, I should stop taking the medication immediately." c. "I may develop diabetes while I am taking this medication." d. "I should not be alarmed if my urine turns reddish-brown."
ANS: D Phenytoin will cause reddish-brown colored urine. Patients should be counseled to report a rash to the provider because it could be a serious adverse reaction. Bleeding gums are common, but patients should never stop taking anticonvulsants abruptly, or they may develop seizures. Changes in blood glucose may occur but do not necessarily result in diabetes.
The patient has not responded to other oral anticonvulsant drug therapy. which drug would the nurse expect to be prescribed for this patient? a. carbamazepine (tegretol) b. diazepam (valium) c. ethosuximide (zarontin) d. valproic acid
a
What would the nurse expect to see if the patient is experiencing a common side effect of phenytoin? a. gingival hyperplasia b. excessive thirst c. weight gain d. muscle tremors
a
Which anticonvulsants is/are classified as pregnancy catefory C? (select all that apply) a. acetazolamide (Diamox) b. carbamazepine (Tegretol) c. Phenobarbital d. pregabalin (Lyrica) e. Topiramate (Topamax)
a & d
The patient has just been diagnosed with a seizure disorder and has been started on valproic acid. what statements by the patient indicates to the nurse that the patient needs more instruction regarding his medication? (select all that apply) a. I just have to remember to take it once a day b. I have to take it with lots of water c. I need to take it at the same times every day d. I cant drink grapefruit juice anymore
a, b, d
A nurse working triage in the emergency department witnesses a patient having a seizure. What info will be included in the nurses documentation? a. type of movements b. duration of movements c. ability to stop movements d. progression of movements e. preceding events
a, b, d, e
Which statements are true about seizures and anticonvulsant use in pregnancy? (select all that apply) a. seizures may increase up to 25% in epileptic women b. many anticonvulsants have teratogenic properties c. anticonvulsant use increases loss of folic acid d. antivonculsants increase the effects of vitamin K e. valproic acid causes malformation in 40% to 80% of fetuses
a,b,c
Phenytoin levels must be monitored carefully as there is a narrow therapeutic range. Which results is within range? a. 8 mcg/mL b. 18 mcg/mL c. 28 mcg/mL d. 38 mcg/mL
b
The patient has a seizure disorder and has just discovered that she is pregnant. at her first prenatal visit, she tells the nurse, "I quit taking all of my meds because I don't want anything to be wrong with my baby" what is the nurses best response? a. you cant do that. you have to take your meds b. what meds have been prescribed for you? c. how long have you had seizures? d. when was your last seizure?
b
The patient has just been diagnosed with epilepsy and will be starting phenytoin. The patients spouse asks how this medicine works in the body. What is the nurses best response? a. it inhibits the enzyme that destroys one of the neurotransmitters b. it helps stop the entry of sodium into the cell c. it has not been determined exactly how it prevents seizures d. it increases the amount of calcium that enters the cell
b
The nurse has received an order to administer an initial dose of iv phenytoin to a patient with new onset seizures. What will the nurse check before administering this medication? (select all that apply) a. hourly urine output b. blood glucose levels c. cardiac rhythm d. blood pressure
b, c, d
The nurse is working on a neurosurgery unit. The patient calls the desk to complain that his arm is really burning and feels hot. The patient is receiving IV phenytoin for his grand mal seizures. What is the nurses best action? a. call the doc immediately to change the med to oral b. continue the infusion and reassure the pt c. flush the line with 10 mL of normal saline and continue the infusion d. discontinue the IV and restart the IV infusion in a different site
d