hard · NCLEX-RN Pharmacological and Parenteral Therapies

A client is receiving phenytoin 100 mg three times daily for a seizure disorder. Which findings during the physical assessment require immediate nursing escalation? Select all that apply.

  1. Staggering gait and difficulty maintaining balance
  2. Swollen, bleeding gums that have grown over the teeth
  3. Development of a new blistering rash on the oral mucosa
  4. Uncontrolled horizontal eye movements during lateral gaze
  5. Pinkish-red discoloration of the urine

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