This is because documenting the seizure activity is important for assessing the type, frequency, and severity of seizures, as well as the response to treatment¹. The nurse should note the time of onset and termination of the seizure, the body parts involved, the level of consciousness, the presence of aura or prodrome, the type and pattern of movements, the eye deviation or blinking, the vocalization or breathing changes, the incontinence or salivation, and any postictal symptoms¹².

Choice A is wrong because administering oxygen via nasal cannula is not necessary for a client who has a simple focal seizure. A simple focal seizure is a type of seizure that affects only one part of the brain and does not impair awareness or consciousness³. The client may experience sensory, motor, autonomic, or psychic symptoms, but they do not have generalized convulsions or respiratory compromise³. Oxygen therapy is indicated for clients who have generalized tonic-clonic seizures or status epilepticus, which can cause hypoxia or apnea¹².

Choice C is wrong because inserting an oral airway to prevent tongue biting is not appropriate for a client who has a simple focal seizure. An oral airway is a device that is inserted into the mouth to keep the tongue from blocking the airway and to facilitate ventilation⁴. An oral airway should not be used for clients who are conscious or have a gag reflex, as it can cause injury, vomiting, or aspiration⁴. A client who has a simple focal seizure is fully alert and conscious and does not need an oral airway³. Tongue biting is rare in simple focal seizures and more common in generalized tonic-clonic seizures.

Choice D is wrong because restraining the client's limbs to prevent injury is not appropriate for a client who has a simple focal seizure. Restraining a client during a seizure can cause more harm than good, as it can increase agitation, prolong the seizure, or cause fractures or dislocations¹². A client who has a simple focal seizure may have involuntary movements of one part of the body, such as twitching or jerking of an arm or leg³. The nurse should not restrain these movements but rather protect the client from hitting any hard or sharp objects¹².

Nystagmus is a sign of phenytoin toxicity, which is caused by overdose, dosage changes, drug interactions, or physiological alterations. Nystagmus is a rapid, involuntary movement of the eyes, which can impair vision and balance. Nystagmus can occur at phenytoin levels above 20 mcg/mL¹².

Choice B is wrong because bradycardia, or slow heart rate, is not a common sign of phenytoin toxicity. Bradycardia can occur in rare cases of phenytoin overdose, especially if the drug is given intravenously too fast¹⁵. However, it is not a reliable indicator of phenytoin toxicity.

Choice C is wrong because hypertension, or high blood pressure, is not a sign of phenytoin toxicity. Hypertension can occur in some patients with seizures, but it is not related to phenytoin levels. Normal blood pressure ranges are less than 120/80 mm Hg for adults⁷⁹.

Choice D is wrong because hyperreflexia, or increased reflexes, is not a sign of phenytoin toxicity. Hyperreflexia can occur in some neurological disorders, such as multiple sclerosis or spinal cord injury, but it is not associated with phenytoin levels. Normal reflexes are graded from 0 to 4+, with 2+ being the average.

Corpus callosotomy is a surgical procedure that involves cutting the corpus callosum, the band of nerve fibers that connects the two hemispheres of the brain. This surgery aims to reduce the frequency and severity of generalized seizures, especially drop attacks, by preventing the spread of epileptic activity from one side of the brain to the other²³. After surgery, it is important to monitor the patient's neurologic status, including level of consciousness, pupillary response, motor function, and sensory function, to detect any complications or changes in seizure activity¹².

Choice B is wrong because prophylactic antibiotics are not routinely given before corpus callosotomy. Antibiotics may be used to treat infections that occur after surgery, such as meningitis or wound infection, but they are not indicated for prevention¹².

Choice C is wrong because instructing the patient to avoid coughing or sneezing after surgery is not a specific intervention for corpus callosotomy. Coughing or sneezing may increase intracranial pressure and cause discomfort, but they are not likely to affect the outcome of the surgery or cause complications¹².

Choice D is wrong because elevating the head of the bed to 45 degrees after surgery is not recommended for corpus callosotomy. Elevating the head of the bed may help reduce cerebral edema and improve venous drainage, but it may also increase the risk of bleeding or air embolism¹². The optimal position for the patient after corpus callosotomy is supine with the head in a neutral position¹².