Question

A newly admitted client reports taking phenytoin for several months. Which assessment should the nurse include in the admission report? Select all that apply.

Report of unsteady gait, rash, and diplopia Correct Answer (Blank)
Serum phenytoin levels Correct Answer (Blank)
Report of anorexia, numbness, and tingling of the extremities
Report of any seizure activity

Answer 1

The nurse should assess for unsteady gait, skin rash, diplopia, serum phenytoin levels, numbness and tingling of the extremities, and any seizure activity in a patient reporting long-term phenytoin use.

Step-by-step explanation:

A newly admitted client reports taking phenytoin for several months. When assessing a patient on phenytoin, which is used to manage seizures, the nurse should perform certain specific assessments. These include noting any reports of an unsteady gait, skin rash, and diplopia, which are possible side effects of the medication. Additionally, it's crucial to check serum phenytoin levels to ensure they are within the therapeutic range to prevent toxicity. Reports of anorexia, numbness, and tingling of the extremities are also relevant as these could be signs of phenytoin side effects or toxicity. Lastly, it is essential to document any seizure activity because it may indicate that the drug regimen needs to be adjusted.