a client with a history of seizures is receiving phenytoin dilantin the nurse should monitor the client for which of the following side effects
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Nursing Elites

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Community Health HESI Test Bank 2023

1. A client with a history of seizures is receiving phenytoin (Dilantin). The nurse should monitor the client for which of the following side effects?

Correct answer: C

Rationale: The correct answer is C: Gingival hyperplasia. Phenytoin can cause gingival hyperplasia, characterized by an overgrowth of gum tissue. It is important for the nurse to monitor the client for this side effect as it can lead to oral health issues. Choices A, B, and D are incorrect. Phenytoin does not typically cause hypertension, hyperglycemia, or hypokalemia as common side effects.

2. When assessing a child with acute respiratory infection, what nursing intervention(s) would be appropriate?

Correct answer: B

Rationale: In the management of acute respiratory infection in a child, it is essential to address various aspects of care. Providing safe remedies to relieve symptoms like sore throat and cough (Choice A) helps in managing discomfort. Advising the mother to monitor for signs of pneumonia (Choice C) is crucial for early detection and intervention if complications arise. Ensuring proper nutrition (Choice D) is important for the child's overall health and immune function during illness. Therefore, all the listed interventions are appropriate in managing acute respiratory infection, making Choice B the correct answer. Choices A, C, and D are incorrect on their own as they address only specific aspects of care and not the comprehensive management of acute respiratory infection.

3. When admitting a client with Parkinson's disease to the home healthcare service, which nursing diagnosis should have priority in planning care?

Correct answer: A

Rationale: The correct answer is A: 'Impaired physical mobility related to muscle rigidity and weakness.' For a client with Parkinson's disease, impaired physical mobility is a priority nursing diagnosis because of the characteristic motor symptoms such as muscle rigidity, bradykinesia, and postural instability. Addressing impaired physical mobility is crucial to enhance the client's quality of life. Choices B, C, and D are not the priority nursing diagnoses for a client with Parkinson's disease. Ineffective coping (Choice B) and fear of seizures (Choice D) may be concerns but are not the priority. Ineffective breathing pattern (Choice C) is not typically associated with Parkinson's disease.

4. A home health nurse knows that a 70-year-old male client who is convalescing at home following a hip replacement is at risk for developing decubitus ulcers. Which physical characteristic of aging contributes to such a risk?

Correct answer: C

Rationale: Thinning of the skin with loss of elasticity is the physical characteristic of aging that contributes to an increased risk of developing decubitus ulcers. As individuals age, the skin becomes thinner and loses its elasticity, making it more susceptible to damage from pressure, leading to the formation of pressure ulcers. Choices A, B, and D are incorrect as they do not directly contribute to the development of decubitus ulcers in this context.

5. The delivery of basic health services was decentralized to the local government units. The legal basis for this is embodied in:

Correct answer: C

Rationale: The correct answer is C, RA 7160. This law, also known as the Local Government Code, decentralizes health services to local government units. RA 7035 is not the legal basis for decentralizing basic health services. EO 119 and PD 999 are also not the correct legal bases for the decentralization of health services.

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