Chapter 19

Question 1

The nurse is caring for several patients, each of whom is being treated with anticonvulsants. Which patient will the nurse assess first?

A) a patient started on valproic acid with a creatinine level of 3
B) a patient started on pregabalin who has partial seizures
C) a patient taking tiagabine who has partial seizures
D) a patient taking levetiracetam and is on multiple drug therapy

Answer 1

A) a patient started on valproic acid with a creatinine level of 3

As valproic acid is excreted by the kidneys, this level is cause for concern because the drug could become toxic. The other patients do not demonstrate any areas outside of the therapeutic range.

Normal Creatinine Levels:
Males: 0.6-1.2 mg/dL
Females: 0.5-1 mg/dL

Question 2

While obtaining a patient history, the nurse notes that the patient has been prescribed ethosuximide. What is the nurse’s primary assessment?

A) assess patient for absence seizures
B) assess patient for panic attacks
C) assess patient for migraines
D) assess patient for tonic-clonic seizures

Answer 2

A) assess patient for absence seizures

Ethosuximide is the first-line drug of choice to treat absence seizures.

Question 3

The patient receiving phenytoin (Dilantin) has a serum drug level of 12 mcg/mL. What is the nurse’s best action?

A) perform a neurological assessment
B) assess the patient’s gums and mouth
C) call the health care provider
D) continue to monitor the patient

Answer 3

D) continue to monitor the patient

Therapeutic serum drug level for phenytoin (Dilantin) is 10 to 20 mcg/mL. The nurse should continue to monitor. Since the drug is at the therapeutic level, there is no need to intervene further by calling the health care provider or performing a more in-depth assessment.

Question 4

A patient asks the nurse why she is receiving a different drug than her usual phenytoin. The patient is to have nothing by mouth and is receiving intravenous fosphenytoin. What is the nurse’s best response?

A) “your serum phenytoin levels were not therapeutic, so your health care provider has changed your medication to a more effective drug”
B) “phenytoin is not effective while you are to have nothing by mouth, so your health care provider has changed your medication to a more effective drug”
C) “fosphenytoin is converted to phenytoin once it is in your bloodstream. Since you are not taking anything by mouth, IV fosphenytoin is easier on your veins than phenytoin”
D) “since you are not taking medication by mouth, you cannot take phenytoin orally. Phenytoin does not come in an intravenous form. You will resume phenytoin after you recover from this illness”

Answer 4

C) “fosphenytoin is converted to phenytoin once it is in your bloodstream. Since you are not taking anything by mouth, IV fosphenytoin is easier on your veins than phenytoin”

Fosphenytoin is a prodrug of phenytoin developed to minimize the irritating effects of phenytoin on blood vessels. Compared to phenytoin, the pH of fosphenytoin is less alkaline and easier on the veins. Once administered, it is converted in the body to phenytoin.

Question 5

The nurse is monitoring phenytoin being infused intravenously at 55 mg/min. What action will the nurse take next?

A) continue to monitor the infusion
B) have the drug changed to PO
C) decrease the infusion and assess blood pressure
D) increase the infusion

Answer 5

C) decrease the infusion and assess blood pressure

Infusing phenytoin at rates >50 mg/min can cause severe hypotension or cardiac dysrhythmias. The infusion should not be increased or discontinued.

Question 6

The patient has been taking phenobarbital to control seizures. The patient complains to the nurse of experiencing occasional stomach upset when taking the medication. What is the nurse’s best response?

A) “you can take the medication with food or milk”
B) “you should take the medication on an empty stomach”
C) “you should call your health care provider because the dose may need to be adjusted”
D) “you should call your health care provider because the drug may need to be stopped”

Answer 6

A) “you can take the medication with food or milk”

The medication can be taken with food or milk to minimize gastric distress, which is an expected side effect of the medication.

Question 7

The nurse is caring for several patients, each of whom has a history of seizure activity. Which patient will the nurse assess first?

A) a patient who has absence seizures
B) a patient who has sensory seizures
C) a patient who is postictal
D) a patient who is taking diazepam

Answer 7

C) a patient who is postictal

The patient who is postseizure may be disoriented and not fully conscious. As safety is a primary concern, the nurse should assess this patient first. The patient with absence seizures, patient with sensory seizures, and patient who is taking diazepam (Valium) do not have the safety issues experienced by the postictal patient.

Question 8

The nurse assesses a patient taking phenytoin and finds gingival hyperplasia. What is the nurse’s priority action?

A) instruct the patient on oral hygiene
B) call for a consult with a dentist
C) call the health care provider
D) hold the next dose of the drug

Answer 8

A) instruct the patient on oral hygiene

A side effect of phenytoin (Dilantin) is overgrowth of gum tissue. This can be minimized by frequent oral hygiene. If oral hygiene efforts do not improve gum condition, a consult with a dentist is recommended. Since this is an expected side effect, there is no indication to notify the health care provider or to hold the next dose.

Question 9

What information will the nurse teach the patient who is considering stopping the antiepileptic drug phenytoin?

A) you may go into status epilepticus
B) you may have an acute withdrawal
C) you will have severe hypotension
D) you may become confused and delirious

Answer 9

A) you may go into status epilepticus

Abrupt withdrawal of antiepileptic drugs can cause the development of status epilepticus. However, stopping phenytoin should not result in acute withdrawal, severe hypotension, or confusion.

Question 10

The patient is noted to experience isolated clonic contractions lasting 3 to 10 seconds and limited to one limb. The nurse identifies this activity as which type of seizure?

A) massive myoclonic seizure
B) Jacksonian seizure
C) grand mal seizure
D) focal myoclonic seizure

Answer 10

D) focal myoclonic seizure

Focal myoclonic activity consists of isolated clonic contractions that last 3 to 10 seconds that are limited to one limb. The patient’s type of seizure is not indicative of massive myoclonic, Jacksonian, or grand mal seizures.

Question 11

Which lab finding would alert the nurse to hold the administration of phenytoin and notify the health care provider?

A) white cell count of 7000 per mcL
B) albumin level of 2.9 g/dL
C) respiration rate of 14
D) pulse rate of 92

Answer 11

B) albumin level of 2.9 g/dL

The nurse would hold phenytoin in the presence of a low albumin rate. Phenytoin is a highly protein-bound (90% to 95%) drug; therefore a decrease in serum protein or albumin can increase the free phenytoin serum level. The white blood cell count is within normal limits as are the pulse and respiratory rate.

Normal Serum Albumin Level: 3.4-4.8 g/dL

Question 12

What is the primary information the nurse should teach a patient who has just started taking mephobarbital?

A) “do not drive until you determine how you react to the medication”
B) “take the medication on a full stomach”
C) “do not take any over-the-counter medications with this drug”
D) “take this medication for 1 month only and then stop”

Answer 12

A) “do not drive until you determine how you react to the medication”

This medication can cause drowsiness. The nurse must teach the patient to be safe while taking this medication. The drug does not need to be taken on a full stomach or to be taken for a limited period of time. The patient should be advised not to take any sedating medications that are available over the counter, but the patient does not need to discontinue all over-the-counter medications.

Question 13

What is the highest priority nursing diagnosis for a patient taking phenytoin?

A) anxiety
B) risk for falls
C) risk for constipation
D) deficient fluid volume

Answer 13

B) risk for falls

The nursing diagnosis “risk for falls” has the highest priority for a patient taking phenytoin because the drug may lead to side effects of dizziness, decreased coordination, and ataxia (impaired balance or coordination). Anxiety, constipation, and deficient fluid volume are not side effects of phenytoin, but depression and discoloration of urine are.

Question 14

Before administering a daily dose of phenytoin, it is most important for the nurse to:

A) maintain the patient on bed rest
B) check phenytoin levels
C) monitor intake and output
D) monitor renal function tests

Answer 14

B) check phenytoin levels

Checking the phenytoin level is most important because of the narrow therapeutic range of 10 to 20 mcg/mL. Maintaining bed rest and monitoring I&O and renal function tests are not necessary.

Question 15

A patient was discharged 3 days ago on phenytoin therapy for seizure disorder. The patient comes to the emergency department experiencing seizures. What will be of most value to determine the etiology of the returned seizures?

A) a CT scan
B) an EEG
C) serum phenytoin levels
D) serum electrolytes

Answer 15

C) serum phenytoin levels

For phenytoin (Dilantin) therapy to be effective, a therapeutic serum range of 10 to 20 mcg/mL must be maintained. Subtherapeutic serum levels are a frequent cause of seizures for patients on phenytoin (Dilantin) therapy.

Question 16

When assessing a patient taking hydantoin therapy for seizure disorder, which indicates an adverse reaction to this therapy?

A) thrombocytopenia
B) leukocytosis
C) gingival atrophy
D) hypoglycemia

Answer 16

A) thrombocytopenia

Severe side effects of hydantoins include thrombocytopenia (low platelet count), leukopenia (low WBC count), gingival hyperplasia (gum overgrowth), and hyperglycemia (high blood sugar). Leukocytosis describes high WBC count, gingival atrophy describes gum loss and hypoglycemia is low blood sugar, so those would not be considered adverse reactions to hydantoin therapy.

Question 17

A patient is experiencing status epilepticus. The nurse anticipates immediate administration of which drug?

A) phenobarbital
B) phenytoin
C) valproic acid
D) diazepam

Answer 17

D) diazepam

Diazepam (Valium) or lorazepam (Ativan) are the drugs of choice for status epilepticus administered IV, followed by IV administration of phenytoin (Dilantin). For continued seizures, midazolam (Versed) or propofol (Diprivan) is used followed by high-dose barbiturates.

Question 18

The nurse witnesses a patient’s seizure involving generalized contraction of the body followed by jerkiness of the arms and legs. The nurse reports this as which type of seizure?

A) myoclonic
B) absence
C) tonic-clonic
D) psychomotor

Answer 18

C) tonic-clonic

Question 19

Phenytoin has been prescribed for a patient with seizures. The nurse should include which appropriate nursing intervention in the plan of care?

A) report an abnormal phenytoin level of 18 mcg/mL
B) monitor complete blood count levels for early detection of blood dyscrasias
C) encourage the patient to brush teeth vigorously to prevent plaque buildup
D) teach the patient to stop the drug immediately when passing pinkish-red or reddish-brown urine

Answer 19

B) monitor complete blood count levels for early detection of blood dyscrasias

Question 20

When administering phenytoin, the nurse realizes more teaching is needed if the patient makes which statement?

A) “I must shake the oral suspension very well before pouring it in the dose cup”
B) “I cannot drink alcoholic beverages when taking phenytoin”
C) “I should take phenytoin 1 hour before meals”
D) “I will need to get periodic dental checkups”

Answer 20

C) “I should take phenytoin 1 hour before meals”

Phenytoin should be taken at the same time every day with food or milk.

Question 21

A patient is having absence seizures. Which of the following does the nurse expect to be prescribed for this type of seizure? (Select all that apply)

A) phenytoin
B) phenobarbital
C) valproic acid
D) clonazepam
E) ethosuximide

Answer 21

C) valproic acid
D) clonazepam
E) ethosuximide

Look at purple chart on pg. 253 in the textbook.

Question 22

A patient is admitted to the emergency department with status epilepticus. Which drug should the nurse most likely prepare to administer to this patient? (Select all that apply)

A) diazepam
B) midazolam
C) gabapentin
D) levetiracetam
E) topiramate

Answer 22

A) diazepam
B) midazolam

Look at pg. 254 in the textbook.

Question 23

The nurse should monitor the patient receiving phenytoin for which adverse effect?

A) psychosis
B) nosebleeds
C) hypertension
D) gum erosion

Answer 23

B) nosebleeds

Question 24

A nurse administering valproic acid to a patient checks the laboratory values and finds a serum range for valproic acid of 150 mcg/mL. What should the nurse do?

A) increase the daily dose to get the patient’s level into the therapeutic range
B) hold the morning dose but give the other scheduled dosages for the day
C) ask the patient if he or she is having any adverse effects from the medication
D) hold the medication and notify the health care provider

Answer 24

D) hold the medication and notify the health care provider

The therapeutic serum range for valproic acid is 50-100 mcg/mL.