A patient on chronic phenytoin for seizure disorder reports … | MyMerci
NCLEX-RN PPT
Question

A patient on chronic phenytoin for seizure disorder reports new diplopia and unsteady gait. The phenytoin level is 28 mcg/mL (therapeutic 10 to 20). Which is the most appropriate nursing action?

Explanation
Phenytoin therapeutic range is 10 to 20 mcg/mL. Level 28 represents toxicity. Classic toxicity findings: nystagmus (the earliest sign), diplopia, ataxia, slurred speech, confusion. Action: HOLD the dose, notify provider for dose adjustment, place on fall precautions, and complete neurologic assessment. Doubling the dose (3) is dangerous; activated charcoal (4) is not appropriate for chronic toxicity (it is used in acute overdose within ~1 hour of ingestion).

In-depth explanation

Phenytoin levels and signs are highly testable: 10-20 therapeutic, 20-30 nystagmus + diplopia + ataxia, 30-40 lethargy, > 40 coma/seizures (paradoxically). The earliest detectable sign is horizontal nystagmus on lateral gaze — assess routinely.

Clinical scenario

Patient on chronic phenytoin reports new diplopia and unsteady gait. Phenytoin level 28 mcg/mL (therapeutic 10-20). Vital signs stable, no active seizing.

Key concepts

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