The nurse is caring for a client with a traumatic brain injury who is at risk for seizures. The healthcare provider prescribes phenytoin. Which laboratory value should the nurse monitor while the client is receiving this medication?

Correct Answer: B

Rationale: Phenytoin, an anticonvulsant, requires monitoring liver function tests (B) due to hepatotoxicity risk. Potassium (A), BUN (C), or WBC (D) aren't primary. B is correct. Rationale: Liver metabolism of phenytoin can elevate enzymes, necessitating regular checks, per pharmacology, to prevent toxicity in brain injury care.

Correct Answer: D

Rationale: Using a quick-release knot to secure a vest restraint ensures safety by allowing rapid removal in emergencies, like respiratory distress. Tying to side rails or movable frames risks injury if the bed adjusts, and square knots are hard to undo quickly. Quick-release knots comply with safety standards, balancing restraint necessity with the ability to free the client swiftly, a critical consideration in nursing to prevent harm while managing behavior.

Correct Answer: D

Rationale: In POMR, all caregivers contribute to the problem list, reflecting a holistic view of the client's needs across domains. This interdisciplinary input from nurses, physicians, social workers ensures comprehensive care, like noting spiritual distress alongside physical issues. Limiting to specific roles misses diverse perspectives, a strength of this system in nursing documentation.

Correct Answer: A

Rationale: Skin produces and absorbs vitamin D via UV rays activating its precursor, unlike C, E, or K. Nurses teach this for bone health awareness.

Correct Answer: B

Rationale: Lean men have the highest water percentage, around 60-65%, due to less fat, unlike fat men, women, or fat women. Nurses apply this in fluid assessments.