NERUO

Phenytoin, 100 mg orally three times daily, has been prescribed for a client for seizure control. The nurse reinforces instructions regarding the medication to the client. Which statement by the client indicates an understanding of the instructions?

"I will use a soft toothbrush to brush my teeth." Gingival hyperplasia, bleeding, swelling, and tenderness of the gums can occur with the use of this medication. The client needs to be taught good oral hygiene, gum massage, and the need for regular dentist visits.

The client is taking phenytoin for seizure control, and a blood sample for a serum drug level is drawn. Which laboratory finding indicates a therapeutic serum drug result?

15 mcg/mL (59.52 mcmol/L) Rationale:The therapeutic serum drug level range for phenytoin is 10 to 20 mcg/mL (39.68 to 79.36 mcmol/L).

The client with myasthenia gravis becomes increasingly weak. The primary health care provider (PHCP) prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which change in condition indicates that the client is in cholinergic crisis?

A temporary worsening of the condition Rationale:An edrophonium injection makes the client experiencing cholinergic crisis temporarily worse. This is known as a negative test. An improvement of weakness would occur if the client were experiencing myasthenia gravis.

The client with myasthenia gravis is receiving pyridostigmine. The nurse monitors for signs and symptoms of cholinergic crisis caused by overdose of the medication. The nurse checks the medication supply to ensure that which medication is available for administration if a cholinergic crisis occurs?

Atropine sulfate Rationale:The antidote for cholinergic crisis is atropine sulfate.

The nurse is reviewing the client's health record and notes that the client elicited a positive Romberg sign. Based on this finding, the nurse would institute which interventions?

Collect data to determine factors for fall risk, Instruct the client to ask for assistance when getting up to walk. Rationale:In the Romberg test, the client is asked to stand with the feet together and the arms at the sides, close the eyes, and hold the position. Normally the client can maintain posture and balance. A positive Romberg is a vestibular neurological sign that is found when a client elicits a loss of balance when closing the eyes. This may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function. The nurse should determine the client's risk for falling by collecting data. Because the client has difficulty maintaining balance, the nurse should instruct the client to ask for assistance when getting up or walking.

The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure (ICP) if the nurse observes the client doing which activity?

Exhaling during repositioning Rationale:Activities that increase intrathoracic and intraabdominal pressures cause indirect elevation of the ICP. Some of these activities include isometric exercises, Valsalva maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising.

The nurse is assigned to care for an adult client who had a stroke and is aphasic. Which interventions would the nurse use for communicating with the client?

Face the client when talking, Speak slowly and maintain eye contact, Use gestures when talking to enhance words, Give the client directions using short phrases and simple terms. Rationale:A client who is aphasic has difficulty expressing or understanding language. The nurse should face the client when talking, establish and maintain eye contact, and speak slowly and distinctly. The nurse should use gestures and pantomime when talking to enhance words and use body language to enhance the message. The nurse should give the client directions using short phrases and simple terms, and phrase questions so that they can be answered with a yes or no. If there is a need to repeat something, the nurse should use the same words a second time.

The client with myasthenia gravis is suspected of having cholinergic crisis. Which sign/symptom indicates this crisis is taking place?

Hypertension Rationale:Cholinergic crisis occurs as a result of an overdose of medication. Indications of cholinergic crisis include gastrointestinal disturbances, nausea, vomiting, diarrhea, abdominal cramps, increased salivation and tearing, miosis, hypertension, sweating, and increased bronchial secretions.

Carbidopa-levodopa is prescribed for a client with Parkinson's disease, and the nurse monitors the client for adverse effects of the medication. Which sign/symptom indicates the client is experiencing an adverse effect?

Impaired voluntary movements

The nurse is caring for a client with increased intracranial pressure (ICP). Which change in vital signs would occur if ICP is rising?

Increasing temperature, decreasing pulse, decreasing respirations, increasing BP

The client with spinal cord injury is prone to experiencing autonomic dysreflexia. The least appropriate measure to minimize the risk of autonomic dysreflexia is which action?

Limiting bladder catheterization to once every 12 hours Rationale:The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be performed every 4 to 6 hours, and indwelling bladder catheters should be checked frequently for kinks in the tubing. It is not appropriate to catheterize the client every 12 hours. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

The client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking vital signs, which immediate action would the nurse take?

Raise the head of the bed and remove the noxious stimulus.

The nurse is assisting with caring for a client after a craniotomy. Which are the positions that can be used for the client?

Semi-Fowler's position and With the foot of the bed flat Rationale:After a craniotomy, the client is at risk for developing complications of increased intracranial pressure and cerebral edema. The head of the bed is elevated 30 degrees (semi-Fowler's position), and the client's head is maintained in a midline, neutral position to facilitate venous drainage. The foot of the bed should be flat because flexion at the hips will impair venous drainage.

The client has clear fluid leaking from the nose after a basilar skull fracture. The nurse determines that this is cerebrospinal fluid (CSF) if the fluid meets which criteria?

Separates into concentric rings and tests positive for glucose

The nurse is caring for the client who has suffered spinal cord injury. The nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication if which sign/symptom is noted?

Severe, throbbing headache Rationale:The client with spinal cord injury above the level of T7 is at risk for autonomic dysreflexia. It is characterized by a severe, throbbing headache, flushing of the face and neck, bradycardia, and sudden severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. It is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury.

The nurse notes the physical assessment findings for a client with a diagnosis of possible meningitis. Which findings would the nurse expect to observe because of meningeal irritation?

The client reports stiffness and soreness in the neck area, The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended, The client reports pain in the vertebral column and passively flexes the hip and knee in response to neck flexion.

The nurse is caring for a client who is taking phenytoin for control of seizures. During data collection, the nurse notes that the client is taking birth control pills. Which information would the nurse provide to the client?

The potential for decreased effectiveness of the birth control pills exists while taking phenytoin. Rationale:Phenytoin enhances the rate of estrogen metabolism, which can decrease the effectiveness of some birth control pills.