Difficulty: Medium
Average Score: 89%
Simulated
A client with a seizure disorder is seen at the clinic for a follow-up visit and a prescription renewal for phenytoin. Which assessment finding warrants immediate intervention by the nurse? Which assessment finding warrants immediate intervention by the nurse?
Correct answer
B
Rationale
Double vision indicates phenytoin toxicity, which can impair coordination and increase fall risk. Immediate intervention, such as notifying the provider and checking serum levels, prevents complications like ataxia or seizures. Gums and insomnia are less urgent side effects.