A nurse is caring for a client who has a history of epilepsy and is taking phenytoin. The nurse notes that the client has swollen and bleeding gums. What is the most appropriate action for the nurse to take?

The correct answer is choice:

B. Instruct the client to use a soft toothbrush and floss gently. This is because phenytoin can cause gingival hyperplasia, which is an enlargement of the gums due to an increase in the number of cells or the size of the gingiva³. This condition can be prevented or minimized by maintaining good oral hygiene and avoiding trauma to the gums².

Choice A is wrong because advising the client to stop taking phenytoin and report to the doctor is not appropriate. Phenytoin is an anticonvulsant medication that is used to treat epileptic seizures, and stopping it abruptly can cause withdrawal symptoms or seizure recurrence¹. The client should not stop taking phenytoin without consulting their doctor, who may adjust the dose or switch to another medication if needed.

Choice C is wrong because administering an oral antiseptic rinse to the client is not effective for treating gingival hyperplasia. Oral antiseptic rinses are used to reduce plaque and bacteria in the mouth, but they do not address the underlying cause of gingival hyperplasia, which is a defect in collagen metabolism³. Oral antiseptic rinses may also have adverse effects such as staining the teeth, altering the taste, or causing mouth irritation².

Choice D is wrong because referring the client to a dentist for evaluation and treatment is not the most appropriate action for the nurse to take. Although a dentist can help diagnose and manage gingival hyperplasia, the nurse should first educate the client about the importance of oral hygiene and instruct them on how to care for their gums. The nurse should also monitor the client's condition and report any changes or complications to the doctor. A dentist referral may be indicated if the gingival hyperplasia is severe or does not respond to oral hygiene measures².

This means that the drug has leaked out of the vein and into the surrounding tissue, causing inflammation, pain, and tissue damage⁵⁶. Phenytoin is a known vesicant, which means it can cause severe skin reactions when extravasated⁵. The clinical manifestation of phenytoin extravasation is called purple glove syndrome (PGS), which is characterized by a purplish to black discoloration of the extremity followed by peripheral edema and pain distal to the site of infusion¹².

Choice A is wrong because the client is not having an allergic reaction to phenytoin. An allergic reaction would cause symptoms such as rash, itching, hives, swelling of the face or throat, difficulty breathing, or anaphylaxis⁷. The client's symptoms are localized to the hand and are consistent with extravasation, not allergy.

Choice B is wrong because the client is not developing purple glove syndrome. Purple glove syndrome is the name of the condition caused by phenytoin extravasation, not a separate entity¹². The client already has purple glove syndrome as a result of the extravasation.

Choice D is wrong because the client is not developing thrombophlebitis. Thrombophlebitis is inflammation of a vein caused by a blood clot, usually in the legs⁸⁹. Thrombophlebitis can cause symptoms such as