A client with psychosis who is receiving an antipsychotic medication is continually rubbing the back of the neck. Which nursing intervention is best for the nurse to implement?

Choice A reason: This is not an assessment finding that warrants immediate intervention by the nurse. Blood pressure 100/78 mm Hg is within the normal range for an adult, and it does not indicate any adverse effect of phenytoin. The nurse should monitor the blood pressure for any changes, but it is not a priority.

Choice B reason: This is an assessment finding that warrants immediate intervention by the nurse. Double vision, or diplopia, is a sign of phenytoin toxicity, which can occur due to overdose, drug interactions, or impaired metabolism. Double vision can impair the client's vision, balance, and coordination, and increase the risk of falls and injuries. The nurse should stop the phenytoin infusion, if applicable, and notify the healthcare provider. The nurse should also check the serum phenytoin level and other vital signs, and prepare to administer an antidote, such as fosphenytoin, if indicated.

Choice C reason: This is not an assessment finding that warrants immediate intervention by the nurse. Puffy, bleeding gums are a common side effect of phenytoin, which can cause gingival hyperplasia, or overgrowth of the gum tissue. Puffy, bleeding gums are not life-threatening, but they can affect the client's oral hygiene and appearance. The nurse should instruct the client to brush and floss the teeth regularly, and to visit a dentist for dental care.

Choice D reason: This is not an assessment finding that warrants immediate intervention by the nurse. Chronic insomnia is not a common or serious side effect of phenytoin, which is an anticonvulsant that can have sedative effects. Chronic insomnia may be caused by other factors, such as stress, pain, or caffeine intake. The nurse should assess the client's sleep pattern and quality, and provide education and counseling on sleep hygiene and relaxation techniques.

Choice A reason: This is not the most important adverse effect for the nurse to report. Nausea is a common side effect of metoclopramide, which is a prokinetic and antiemetic drug that stimulates the motility of the upper GI tract and blocks the dopamine receptors in the chemoreceptor trigger zone. Nausea may be mild or moderate, and it may subside with time or dose adjustment. The nurse should monitor the client's nausea and provide supportive measures, such as fluids, crackers, or ginger, but it is not a priority.

Choice B reason: This is the most important adverse effect for the nurse to report. Involuntary movements, or extrapyramidal symptoms, are a serious and potentially irreversible side effect of metoclopramide, which can occur due to the blockade of the dopamine receptors in the basal ganglia. Involuntary movements can include dystonia, akathisia, parkinsonism, or tardive dyskinesia, and they can affect the face, neck, limbs, or trunk. The nurse should assess the client for any signs of involuntary movements and notify the healthcare provider immediately. The nurse should also prepare to administer an anticholinergic drug, such as benztropine, to counteract the effects of metoclopramide.

Choice C reason: This is not the most important adverse effect for the nurse to report. Unusual irritability is a rare and mild side effect of metoclopramide, which may be related to the central nervous system effects of the drug. Unusual irritability may manifest as restlessness, anxiety, or agitation, and it may resolve with time or dose adjustment. The nurse should monitor the client's mood and behavior and provide reassurance and comfort, but it is not a priority.

Choice D reason: This is not the most important adverse effect for the nurse to report. Diarrhea is a rare and mild side effect of metoclopramide, which may be related to the increased motility of the GI tract. Diarrhea may be transient or self-limiting, and it may be managed with fluids, electrolytes, or antidiarrheal drugs. The nurse should monitor the client's stool frequency and consistency and provide hydration and hygiene, but it is not a priority.