Summary
Summary ( 14 Questions)
The nurse is preparing to give medications to a client who has been receiving long-term therapy with phenytoin (Dilantin). The nurse notes that the client has coarse facial features, hirsutism, and acne. What is the most appropriate nursing diagnosis for this client?
Choice A is wrong because risk for infection related to immunosuppression is not a relevant nursing diagnosis for this client. Phenytoin can cause blood dyscrasias, such as leukopenia and thrombocytopenia, in some people¹²³. However, these side effects are not related to immunosuppression and do not increase the risk of infection¹. The nurse should monitor the client's blood counts and report any signs of bleeding or anemia to the provider¹.
Phenytoin (Dilantin) can cause cosmetic side effects, such as coarse facial features, hirsutism, and acne, in some people¹²³. These side effects can affect the client's self-esteem, social interactions, and emotional well-being¹. The nurse should assess the client's perception of his or her appearance and provide support and education to cope with the changes¹.
Choice C is wrong because impaired skin integrity related to hypersensitivity reaction is not a relevant nursing diagnosis for this client. Phenytoin can cause allergic reactions, such as rash, fever, lymphadenopathy, and hepatitis, in some people¹²³. However, these side effects are not related to impaired skin integrity and do not cause skin breakdown or ulceration¹. The nurse should discontinue the medication and report any signs of hypersensitivity reaction to the provider¹.
Choice D is wrong because deficient knowledge related to self-care and medication management is not a relevant nursing diagnosis for this client. Phenytoin requires careful monitoring and education to ensure therapeutic and safe use¹²³. However, this nursing diagnosis does not address the client's specific concern about the cosmetic side effects of phenytoin¹. The nurse should provide information and counseling about the benefits and risks of phenytoin therapy and discuss alternative options with the provider if needed¹.
Phenytoin (Dilantin) can cause cosmetic side effects, such as coarse facial features, hirsutism, and acne, in some people¹²³. These side effects can affect the client's self-esteem, social interactions, and emotional well-being¹. The nurse should assess the client's perception of his or her appearance and provide support and education to cope with the changes¹.
Choice A is wrong because risk for infection related to immunosuppression is not a relevant nursing diagnosis for this client. Phenytoin can cause blood dyscrasias, such as leukopenia and thrombocytopenia, in some people¹²³. However, these side effects are not related to immunosuppression and do not increase the risk of infection¹. The nurse should monitor the client's blood counts and report any signs of bleeding or anemia to the provider¹.
Choice C is wrong because impaired skin integrity related to hypersensitivity reaction is not a relevant nursing diagnosis for this client. Phenytoin can cause allergic reactions, such as rash, fever, lymphadenopathy, and hepatitis, in some people¹²³. However, these side effects are not related to impaired skin integrity and do not cause skin breakdown or ulceration¹. The nurse should discontinue the medication and report any signs of hypersensitivity reaction to the provider¹.
Choice D is wrong because deficient knowledge related to self-care and medication management is not a relevant nursing diagnosis for this client. Phenytoin requires careful monitoring and education to ensure therapeutic and safe use¹²³. However, this nursing diagnosis does not address the client's specific concern about the cosmetic side effects of phenytoin¹. The nurse should provide information and counseling about the benefits and risks of phenytoin therapy and discuss alternative options with the provider if needed¹.