The priority action during a generalized tonic-clonic seizure is to protect the airway.

Option B: Administration of lorazepam should be the next action since it will act rapidly to control the seizure.
Option A: Although oxygen may be useful during the postictal phase, the hypoxemia during tonic-clonic seizures is caused by apnea.
Option D: Checking the level of consciousness is not appropriate during the seizure, because generalized tonic-clonic seizures are associated with a loss of consciousness.

Leukopenia is a serious adverse effect of phenytoin and would require discontinuation of the medication.

Option A: Inflammation of the gums should be reported to the physician, but it does not require immediate attention.
Option C: The nurse should include in the patient teaching the importance of taking medications on time to avoid episodes of seizure.
Option D: Driving is prohibited for a client with a seizure disorder. This should be included in the patient’s teaching, but will not require a change in medical treatment for the seizures.

Urinary tract infections are a frequent complication in patients with multiple sclerosis because of the effect on bladder function. The elevated temperature and decreased breath sounds suggest that this patient may have pyelonephritis. The physician should be notified immediately so that antibiotic therapy can be started quickly.

Option A: This patient needs further assessment, but does not require immediate attention. A migraine can cause severe throbbing pain or a pulsing sensation, usually on one side of the head. It’s often accompanied by nausea, vomiting, and extreme sensitivity to light and sound. Migraine attacks can last for hours to days, and the pain can be so severe that it interferes with daily activities.
Option B: Preoperative teaching must be done but it is not the nurse’s priority. A craniotomy is the surgical removal of part of the bone from the skull to expose the brain. Specialized tools are used to remove the section of bone called the bone flap. The bone flap is temporarily removed, then replaced after the brain surgery has been done.
Option C: The patient should be assessed soon, but does not have an urgent need. In MS, the immune system attacks the protective sheath (myelin) that covers nerve fibers and causes communication problems between your brain and the rest of your body. Eventually, the disease can cause permanent damage or deterioration of the nerves.

NA education and scope of practice includes taking pulse and blood pressure measurements. In addition, NAs can reinforce previous teaching or skills taught by the RN or other disciplines, such as speech or physical therapists.

Option B: Evaluation of patient response to medication requires the knowledge of an experienced RN.
Option D: Development and individualizing the plan of care require RN-level education and scope of practice.

LPN education and team leader responsibilities include checking for the therapeutic and adverse effects of medications. Changes in the residents’ memory would be communicated to the RN supervisor, who is responsible for overseeing the plan of care for each resident.

Option B: Assessment for changes on the Mini-Mental State Examination is an RN responsibility.
Option C: Assisting residents with personal care and hygiene would be delegated to nursing assistants working in the LTC facility.
Option D: Developing an activity plan should be done by an RN.