A nurse is obtaining a health history from the family of a patient who has a history of seizures and is being treated with phenytoin (Dilantin)
The patient was brought to the emergency department and was unresponsive to voice or touch. The family states that the patient had been drinking alcohol all afternoon. What further assessment is indicated by the nurse?
a. The nurse should assess for other signs of central nervous system depression.
b. The nurse should suspect that a grand mal seizure has occurred.
c. The nurse should assess for gingival hyperplasia.
d. The nurse should gather more information from the family.
ANS: A
The depressant effects of alcohol potentiate the central nervous system effects of phenytoin.
No evidence indicates that a grand mal seizure has occurred.
Gingival hyperplasia is an expected side effect with phenytoin and is not related to the patient's alcohol use.
The nurse should begin the assessment, because the family has provided the pertinent information about the patient's current state.
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