Get Answer: Nurse Provides Care Question Guide

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Original Question

The nurse provides care for an adult patient who presented to the ED with swollen gums impacting oral intake and is admitted to the medical unit for ongoing care. The nurse reviews the patient’s assessment data to prepare the plan of care. Complete the bowtie by dragging and dropping the condition the patient is most likely experiencing, two interventions the nurse would perform/anticipate related to the condition, and two parameters the nurse would monitor. Client Data History and Assessment 12/12/XX Seizure disorder diagnosed during childhood. Prescribed phenytoin (Dilantin) for seizure control for several years. Alert and oriented x 3. PERRLA; moves all extremities. Mucous membranes moist with reddened, swollen gums. Lungs clear to auscultation, regular rate, and rhythm. Heart rate and blood pressure within normal limits (WNL). Integument WNL. Bowel sounds present x 4 quadrants. Nurses’ Notes 12/12/XX 0825 The patient was brought to the emergency department (ED) by their spouse after experiencing gum swelling and bleeding that was causing pain and interfering with oral intake. Over the last 24 hours, the patient’s phenytoin was discontinued with seizure activity x 1 that resolved without pharmacologic intervention. Vital Signs 12/12/XX 0825 Temp. 98.6°F (37°C) HR 82 beats/min RR 16 breaths/min; regular SpO2 99% on room air Blood Pressure 118/68 mm Hg Laboratory Results 12/12/XX 0845 Phenytoin level 22 mcg/dL (10-20 mcg/dL) Action to Take Action to Take Condition Most

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