A client has a brain abscess and is receiving phenytoin ...

[CharlieWard]

A client has a brain abscess and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best?
 
  a. Increased pressure from the abscess can cause seizures.
  b. Preventing febrile seizures with an abscess is important.
  c. Seizures always occur in clients with brain abscesses.
  d. This drug is used to sedate the client with an abscess.

Question 2

A client in the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best?
 
  a. Ensure that informed consent is on the chart.
  b. Document these findings in the client's record.
  c. Give the prescribed preprocedure sedation.
  d. Notify the provider of the findings immediately.

[jaygar71]

Answer to Question 1

ANS: A
Brain abscesses can lead to seizures as a complication. The nurse should explain this to the spouse. Phenytoin is not used to prevent febrile seizures. Seizures are possible but do not always occur in clients with brain abscesses. This drug is not used for sedation.

Answer to Question 2

ANS: D
This client is exhibiting signs of increased intracranial pressure. The nurse should notify the provider immediately because performing the LP now could lead to herniation. Informed consent is needed for an LP, but this is not the priority. Documentation should be thorough, but again this is not the priority. The preprocedure sedation (or other preprocedure medications) should not be given as the LP will most likely be canceled.