Neurologic Health Problems NCLEX Questions with Rationale

Neurologic Health Problems NCLEX Questions with Rationale

Medically reviewed by

By

NCLEX Neurologic Health Problems Questions

Neurologic Health Problems NCLEX Practice Questions

Question 1.    
The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that apply.
(a) Encourage the client to cough to expectorate secretions.
(b) Elevate the head of the bed 15 to 20 degrees.
(c) Contact the health care provider (HCP) if ICP is >28 mm Hg.
(d) Monitor neurologic status using the Glasgow Coma Scale.
(e) Stimulate the client with active range-of-motion exercises.
Answer:
(b) Elevate the head of the bed 15 to 20 degrees.
(c) Contact the health care provider (HCP) if ICP is >28 mm Hg.
(d) Monitor neurologic status using the Glasgow Coma Scale.

Explanation:
(b), (c), (d). The nurse should maintain ICP by elevating the head of the bed 15 to 20 degrees and monitoring neurologic status. An ICP of 28 mm Hg with 20 to 25 mm Hg as upper limits of normal indicates increased ICP, and the nurse should notify the HCP. Coughing and range-of-motion exercises will increase ICP and should be avoided in the early postoperative stage.

Question 2.    
The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators are the most critical for the nurse to monitor? Select all that apply.
(a) systolic blood pressure
(b) urine output
(c) breath sounds
(d) cerebral perfusion pressure
(e) level of pain
Answer:
(a) systolic blood pressure
(d) cerebral perfusion pressure

Explanation:
The nurse must monitor the systolic and diastolic blood pressure to obtain the mean arterial pressure (MAP), which represents the pressure needed for each cardiac cycle to perfuse the brain. The nurse must also monitor the cerebral perfusion pressure (CPP), which is obtained from the ICP and the MAP. The nurse should also monitor urine output, respirations, and pain; however, crucial measurements needed to maintain CPP are ICP and MAP. When ICP equals MAP, there is no CPP.
 
Question 3.    
A nurse is assessing a client with increasing intracranial pressure. What is a client’s mean arterial pressure (MAP) in mm Hg when blood pressure (BP) is 120/60 mm Hg? ............................ mm Hg.
Answer:
80 mm Hg
To obtain the MAP, use this formula:
MAP = [systolic BP + (2 x diastolic BP)] ÷ 3 
MAP = [120+ (2x60)]  ÷ 3 
MAP = 240-3 = 80.

Question 4.    
A client with a contusion has been admitted for observation following a motor vehicle accident when he was driving his pregnant wife to the hospital. The next morning, instead of asking about his wife and baby, he asked to see the football game on television that he thinks is starting in 5 minutes. He is agitated because the nurse will not turn on the television. What should the nurse do next? Select all that apply.
(a) Find a television so the client can view the football game.
(b) Determine if the client’s pupils are equal and react to light.
(c) Ask the client if he has a headache.
(d) Arrange for the client to be with his wife and baby.
(e) Administer a sedative.
Answer:
(b) Determine if the client’s pupils are equal and react to light.
(c) Ask the client if he has a headache.

Explanation:
(b), (c). The nurse should determine if the client’s pupils are equal and react to light, and ask the client if he has a headache. Confusion, agitation, and restlessness are subtle clinical manifestations of increased intracranial pressure (ICP). At this time, it is not appropriate for the nurse to find a television or arrange for the client to see his wife and baby. Administering a sedative at this time will obscure assessment of increased ICP.

Question 5.    
The nurse is assessing the level of consciousness in a client with a head injury who has been unresponsive for the last 8 hours. Using the Glasgow Coma Scale, the nurse notes that the client opens the eyes only as a response to pain, responds with sounds that are not understandable, and has abnormal extension of the extremities. What should the nurse do?
Glasgow Coma Scale

Parameter

Finding

Score

Eye opening

Spontaneously

4

To speech

3

To pain

2

Do not open

1

Best verbal response

Oriented

5

Confused

4

Inappropriate speech

3

Incomprehensible sounds

2

No verbalization

1

Best motor response

Obeys command

6

Localizes pain

5

Withdraws from pain

4

Abnormal flexion

3

Abnormal extension

2

No motor response

1

Interpretation: Best score = 15; worst score = 3; 7 or less generally indicates coma; changes from baseline are most important.
(a) Attempt to arouse the client.
(b) Reposition the client with the extremities in normal alignment.
(c) Chart the client’s level of consciousness as coma.
(d) Notify the health care provider (HCP).
Answer:
(c) Chart the client’s level of consciousness as coma.

Explanation:
(c) The client has a score of 6 (eye opening to pain = 2; verbal response, incomprehensible sounds = 2; best motor response, abnormal extension = 2); a score <7 is indicative of coma. While the nurse should continue to speak to the client, at this time the client will not be able to be aroused. The nurse should continue to provide skin care and appropriate alignment, but the client will continue to have a motor response of limb extension. It is not necessary to notify the HCP as this assessment does not represent a significant change in neurological status.

Question 6.
An unconscious client with multiple injuries to the head and neck arrives in the emergency department. What should the nurse do first?
(a) Establish an airway.
(b) Determine the identity of the client.
(c) Stop bleeding from open wounds.
(d) Check for a neck fracture.
Answer:
(a) Establish an airway.

Explanation:
The highest priority for a client with multiple head and neck injuries is to establish an open airway for effective ventilation and oxygenation. Unless the client has a patent airway, other care measures will be futile. Determining the client’s identity, blood loss, stopping bleeding from open wounds, and checking for a neck fracture are important nursing interventions to be completed after the airway and ventilation are established.
 
Question 7.    
A client has delirium following a head injury. The client is disoriented and agitated. In which order from first to last should the nurse initiate care for this client? All options must be used.
(a) Request a prescription for haloperidol.
(b) Maintain a quiet environment.
(c) Assure the client’s safety. 
(d) Approach the client using short sentences.
Answer:
(d) Approach the client using short sentences.
(c) Assure the client’s safety. 
(b) Maintain a quiet environment.
(a) Request a prescription for haloperidol.

Explanation:
(d), (c), (b), (a). The first step in providing care for a client with delirium is to approach the client calmly, introduce oneself, and use short sentences when explaining the care given. The nurse should also assure the client’s safety by protecting the client from injury. Maintaining a quiet and calm environment by removing extraneous noises will prevent overstimulation. Pharmacologic intervention is used only when other plans for care are not effective. When the underlying problems related to the head injury are resolved, the delirium likely will improve.
 
Question 8.    
A client is at risk for increased intracranial pressure (ICP). Which finding is the priority for the nurse to monitor?
(a) unequal pupil size
(b) decreasing systolic blood pressure
(c) tachycardia
(d) decreasing body temperature
Answer:
(a) unequal pupil size

Explanation:
Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.

Question 9.
What should the nurse do first when a client with a head injury begins to have clear drainage from the nose?
(a) Compress the nares.
(b) Tilt the head back.
(c) Collect the drainage.
(d) Administer an antihistamine for postnasal drip.
Answer:
(c) Collect the drainage.

Explanation:
The clear drainage must be analyzed to determine whether it is nasal drainage or cerebrospinal fluid (CSF). The nurse should not give the client tissues because it is important to know how much leakage of CSF is occurring. Compressing the nares will obstruct the drainage flow. It is inappropriate to tilt the head back, which would allow the fluid to drain down the throat and not be collected for a sample. It is inappropriate to administer an antihistamine because the drainage may not be from a postnasal drip.
 
Question 10. 
Which respiratory pattern indicates increasing intracranial pressure in the brain stem?
(a) slow, irregular respirations
(b) rapid, shallow respirations
(c) asymmetric chest excursion
(d) nasal flaring
Answer:
(a) slow, irregular respirations

Explanation:
Neural control of respiration takes place in the brain stem. Deterioration and pressure produce slow and irregular respirations. Rapid and shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia.
 
Question 11.    
A client has an increased intracranial pressure (ICP) of 20 mm Hg. What should the nurse do next?
(a) Give the client a warming blanket.
(b) Administer low-dose barbiturates.
(c) Encourage the client to take deep breaths to hyperventilate.
(d) Restrict fluids.
Answer:
(c) Encourage the client to take deep breaths to hyperventilate.

A client with increased intracranial pressure has a cerebral perfusion pressure (cpp) of 40 mm hg

Explanation:
Normal ICP is 15 mm Hg or less for 15 to 30 seconds or longer. Hyperventilation causes vasoconstriction, which reduces cerebrospinal fluid and blood volume, two important factors for reducing a sustained ICP of 20 mm Hg. A cooling blanket is used to control the elevation of temperature because a fever increases the metabolic rate, which in turn increases ICP. High doses of barbiturates may be used to reduce the increased cellular metabolic demands. Fluid volume and inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure >80 mm Hg.
 
Question 12.
The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider (HCP) about which early change in the client’s condition?
(a) widening pulse pressure
(b) decrease in the pulse rate
(c) dilated, fixed pupils
(d) decrease in level of consciousness (LOC) 
Answer:
(d) decrease in level of consciousness (LOC) 

Explanation:
A decrease in the client’s LOC is an early indicator of deterioration of the client’s neurologic status. Changes in LOC, such as restlessness and irritability, may be subtle. Widening of the pulse pressure, decrease in the pulse rate, and dilated, fixed pupils occur later if the increased ICP is not treated.

Question 13.
The client has a sustained increased intracranial pressure (ICP) of 20 mm Hg. Which client position would be most appropriate?
(a) the head of the bed elevated 15 to 20 degrees 
(b) Trendelenburg’s position
(c) left Sims’ position 
(d) the head elevated on two pillows
Answer:
(a) the head of the bed elevated 15 to 20 degrees 

Explanation:
The client’s ICP is elevated, and the client should be positioned to avoid extreme neck flexion or extension. The head of the bed is usually elevated 15 to 20 degrees to drain the venous sinuses and thus decrease the ICP. Trendelenburg’s position places the client’s head lower than the body, which would increase ICP. Sims’ position (side lying) and elevating the head on two pillows may extend or flex the neck, which increases ICP.
 
Question 14.    
The nurse administers mannitol to the client with increased intracranial pressure. Which parameter requires close monitoring?
(a) muscle relaxation 
(b) intake and output
(c) widening of the pulse pressure 
(d) pupil dilation
Answer:
(b) intake and output

Explanation:
After administering mannitol, the nurse closely monitors intake and output because mannitol promotes diuresis and is given primarily to pull water from the extracellular fluid of the edematous brain. Mannitol can cause hypokalemia and may lead to muscle contractions, not muscle relaxation. Signs and symptoms, such as widening pulse pressure and pupil dilation, should not occur because mannitol serves to decrease ICP.
 
Question 15.    
The nurse is assessing a client for movement after halo traction placement for a C8 fracture. What should the nurse do to test the client’s ability to move?
Ask the client to:
(a) shrug shoulders against downward resistance.
(b) pull arm up from a resting position against resistance.
(c) straighten arm from a flexed position against resistance.
(d) grasp the nurse’s hands with both hands and squeeze.
Answer:
(d) grasp the nurse’s hands with both hands and squeeze.

Explanation:
The correct motor function test for C8 is a hand-grasp check. The motor function check for C4 to C5 is shoulders shrugging against downward pressure of the examiner’s hands. The motor function check for C5 to C6 is an arm pulling up from a resting position against resistance. The motor function check for C7 is an arm straightening out from a flexed position against resistance.
 
Question 16.
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the IV line. What should the nurse do to protect the client without increasing the intracranial pressure (ICP]?
(a) Place the client in a jacket restraint.
(b) Wrap the hands in soft “mitten” restraints.
(c) Tuck the arms and hands under the sheet.
(d) Apply a wrist restraint to each arm.
Answer:
(b) Wrap the hands in soft “mitten” restraints.

Explanation:
It is best for the client to wear mitts, which help prevent the client from pulling on the IV without causing additional agitation. Using a jacket or wrist restraint or tucking the client’s arms and hands under the sheet restricts movement and adds to feelings of being confined, all of which would add to the agitation and increase ICP.
 
Question 17.
Which activity should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure (ICP)?
(a) deep breathing 
(b) turning 
(c) coughing
(d) passive range-of-motion (ROM) exercises
Answer:
(c) coughing

Explanation:
Coughing is contraindicated for a client at risk for increased ICP because coughing increases ICP. Deep breathing can be continued. Turning and passive ROM exercises can be continued with care not to extend or flex the neck.
 
Question 18.
A client who had a serious head injury with increased intracranial pressure is to be discharged to a rehabilitation facility. Which outcome of rehabilitation would be appropriate for the client?
The client will:
(a) exhibit no further episodes of short-term memory loss.
(b) be able to return to his construction job in 3 weeks.
(c) actively participate in the rehabilitation process as appropriate.
(d) be emotionally stable and display preinjury personality traits.
Answer:
(c) actively participate in the rehabilitation process as appropriate.

Explanation:
Recovery from a serious head injury is a long-term process that may continue for months or years. Depending on the extent of the injury, clients who are transferred to rehabilitation facilities most likely will continue to exhibit cognitive and mobility impairments as well as behavior and personality changes. The client would be expected to partici-pate in the rehabilitation efforts to the extent he is capable. Family members and significant others will need long-term support to help them cope with the changes that have occurred in the client.
  
Question 19. 
Four hours after supratentorial surgery, the client is receiving IV fluid at 80 mL per hour, and the nurse is monitoring the client’s neurological status using the Glasgow Coma Scale. At 1015, the client has turned to the left side and is lying flat. At 1030 the nurse notes the changes in the client’s status (see chart.) What should the nurse do next?

Glasgow Coma Scale

1000

1015

1030

Eye opening

4

4

3

Verbal response

5

5

4

Motor response

6

6

6

(a) Note the changes and continue to assess the client every 15 minutes.
(b) Notify the surgeon of these findings.
(c) Position the client supine with the head of the bed elevated at 30 degrees.
(d) Slow the rate of the IV fluid to 60 mL per hour.
Answer:
(c) Position the client supine with the head of the bed elevated at 30 degrees.

Explanation:
The Glasgow Coma Scale is used to determine the extent of neurological changes, which can include increased intracranial pressure. The decreases in this score are an early indicator of increasing ICP. The nurse should first position the client in the supine position with the head of the bed elevated at 30 degrees. A side-lying position or having the head of the bed elevated beyond 30 degrees can decrease cerebral perfusion.

Continued assessment and a more in-depth neurologic exam will help determine this. If repositioning the client improves the Glasgow score, the nurse does not need to contact the surgeon and should continue to monitor the client for changes. The nurse should determine the total amount of fluid intake before considering any action adjusting the fluid rate.
 
Question 20. 
The nurse is assessing a client’s motor response after brain surgery. The nurse pinches the client’s skin to elicit a response and observes the client’s arms and legs moving straight out and the feet and toes bend downward. How should the nurse document this response?
(a) flaccid paralysis
(b) flexion posturing
(c) chronic spastic paralysis
(d) extension posturing
Answer:
(d) extension posturing

The nurse is assessing a client's motor response after brain surgery. the nurse pinches the client's skin to elicit a response

Explanation:
The client is exhibiting extension posturing indicating severe brain stem or midbrain damage which may be a sign of irreversible damage. Flaccid paralysis occurs when there is no resistance to the passive range of motion or voluntary movement. Flexion posturing is a sign of brain damage and communication with nerves in the spinal cord and not as dangerous a sign as extension posturing. Chronic spastic paralysis results from damage to the voluntary movement system between the brain and the muscles.
 
Question 21.
The nurse is assessing a client with a head injury for decerebrate posturing. Which position indicates the client has decerebrate posturing?
(a) internal rotation and adduction of arms with flexion of elbows, wrists, and fingers
(b) back hunched over and rigid flexion of all four extremities with supination of arms and plantar flexion of feet
(c) supination of arms and dorsiflexion of the feet
(d) back arched and rigid extension of all four extremities
Answer:
(d) back arched and rigid extension of all four extremities

Explanation:
Decerebrate posturing occurs in clients with damage to the upper brain stem, midbrain, or pons and is demonstrated clinically by arching of the back, rigid extension of the extremities, pronation of the arms, and plantar flexion of the feet. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers describes decorticate posturing, which indicates damage to corticospinal tracts and cerebral hemispheres.
 
Question 22. 
A client receiving continuous mandatory ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. What should the nurse do?
(a) Count the rate to be sure that ventilations are deep enough to be sufficient.
(b) Notify the health care provider (HCP) of the client’s breathing pattern.
(c) Increase the rate of ventilations.
(d) Increase the tidal volume on the ventilator.
Answer:
(b) Notify the health care provider (HCP) of the client’s breathing pattern.

Explanation:
Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital lobe, which is just superior and posterior to the pons and medulla, clinical manifestations that indicate a new lesion are monitored very closely in case another bleed ensues. The nurse should notify the HCP QJ immediately so that treatment can begin before respirations cease. The client is not obtaining sufficient oxygen, and the depth of breathing is assisted by the ventilator. The HCP will determine changes in the ventilator settings.
  
Question 23.
The nurse is planning the care for a client who has had a posterior fossa (infratentorial) craniotomy. What should the nurse avoid when positioning the client?
(a) keeping the client flat on one side or the other
(b) elevating the head of the bed to 30 degrees
(c) logrolling or turning as a unit when turning
(d) keeping the neck in a neutral position
Answer:
(b) elevating the head of the bed to 30 degrees

Explanation:
Elevating the head of the bed to 30 degrees is contraindicated for infratentorial craniotomies because it could cause herniation of the brain down onto the brain stem and spinal cord, resulting in sudden death. Elevation of the head of the bed to 30 degrees with the head turned to the side opposite the incision, if not contraindicated by the increased intracranial pressure, is used for supratentorial craniotomies.
 
Question 24. 
A young adult is admitted to the hospital with a head injury and possible temporal skull fracture sustained in a motorcycle accident. On admission, the client was conscious but lethargic; vital signs included temperature 99°F (37°C), pulse 100 bpm, respirations 18 breaths/min, and blood pressure 140/70 mm Hg. The nurse should report which changes should they occur to the health care provider (HCP)? Select all that apply.
(a) decreasing urinary output
(b) decreasing systolic blood pressure
(c) bradycardia
(d) widening pulse pressure
(e) tachycardia
(f) increasing diastolic blood pressure
Answer:
(c) bradycardia
(d) widening pulse pressure

Explanation:
(c), (d). The nurse should immediately report changes that indicate increasing intracranial pressure (ICP): bradycardia, increasing systolic pressure, and widening pulse pressure. As ICP increases and the brain becomes more compressed, respirations become rapid, BP decreases, and the pulse slows further; these are very ominous signs. Decreased arterial BP and tachycardia can indicate bleeding elsewhere in the body. Decreasing urinary output indicates decreased tissue perfusion. The nurse monitors changes and notifies the HCP if trends continue.
 
Question 25. 
A client with a head injury regains consciousness after several days. When the client first awakes, what should the nurse say to the client?
(a) “I’ll get your family.”
(b) “Can you tell me your name and where you live?”
(c) “I’ll bet you are a little confused right now.”
(d) “You’re in the hospital. You were in an accident and unconscious.”
Answer:
(d) “You’re in the hospital. You were in an accident and unconscious.”

Explanation:
It is important to first explain where a client is to orient him or her to time, person, and place. Offering to get the family and asking questions to determine orientation are important, but the first comments should let the client know where he or she is and what has happened. It is useful to be empathetic to the client, but making a comment such as “I’ll bet you are a little confused” is not helpful and may cause anxiety.
 
Question 26. 
The nurse sees a client walking in the hallway who begins to have a seizure. What should the nurse do in order of priority from first to last? All options must be used.
(a) Maintain a patent airway.
(b) Record the seizure activity observed.
(c) Ease the client to the floor.
(d) Obtain vital signs.
Answer:
(c) Ease the client to the floor.
(a) Maintain a patent airway.
(d) Obtain vital signs.
(b) Record the seizure activity observed.

Explanation:
(c), (a), (d), (b). To protect the client from falling, the nurse first should ease the client to the floor.
It is important to protect the head and maintain a patent airway since altered breathing and excessive salivation can occur. The assessment of the postictal period should include level of consciousness and vital signs. The nurse should record details of the seizure once the client is stable. The events preceding the seizure, timing with descriptions of each phase, body parts affected and sequence of involvement, and autonomic signs should be recorded.

Question 27.    
Which finding will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure?
(a) jerking in one extremity that spreads gradually to adjacent areas
(b) vacant staring and abruptly ceasing all activity
(c) facial grimaces, patting motions, and lip smacking
(d) loss of consciousness, body stiffening, and violent muscle contractions
Answer:
(d) loss of consciousness, body stiffening, and violent muscle contractions

Explanation:
A generalized tonic-clonic seizure involves both a tonic phase and a clonic phase. The tonic phase consists of loss of consciousness, dilated pupils, and muscular stiffening or contraction, which lasts about 20 to 30 seconds. The clonic phase involves repetitive movements. The seizure ends with confusion, drowsiness, and resumption of respiration.

A partial seizure starts in one region of the cortex and may stay focused or spread (e.g., jerking in the extremity spreading to other areas of the body). An absence seizure usually occurs in children and involves a vacant stare with a brief loss of consciousness that often goes unnoticed. A complex partial seizure involves facial grimacing with patting and smacking.
 
Question 28.    
It is the night before a client is to have a computed tomography (CT) scan of the head without contrast. What should the nurse tell the client to do to prepare for this test?
(a) “You must shampoo your hair tonight to remove all oil and dirt.”
(b) “You may drink fluids until midnight, but after that, drink nothing until the scan is completed.”
(c) “You will have some hair shaved to attach the small electrode to your scalp.”
(d) “You will need to hold your head very still during the examination.”
Answer:
(d) “You will need to hold your head very still during the examination.”

Explanation:
The client will be asked to hold the head very still during the examination, which lasts about 30 to 60 minutes. In some instances, food and fluids may be withheld for 4 to 6 hours before the procedure if a contrast medium is used because the radiopaque substance sometimes causes nausea. There is no special preparation for a CT scan, so a shampoo the night before is not required. The client may drink fluids until 4 hours before the scan is scheduled. Electrodes are not used for a CT scan, nor is the head shaved. 
 
Question 29.    
The client will have an electroencephalogram (EEG) in the morning. The nurse should instruct the client to have which foods/fluids for breakfast?
(a) no food or fluids
(b) only coffee or tea if needed
(c) a full breakfast as desired without coffee, tea, or energy drinks
(d) a liquid breakfast of fruit juice, oatmeal, or smoothie
Answer:
(c) a full breakfast as desired without coffee, tea, or energy drinks

Explanation:
Beverages containing caffeine, such as coffee, tea, cola, and energy drinks, are withheld before an EEG because of the stimulating effects of caffeine on the brain waves. A meal should not be omitted before an EEG because low blood sugar could alter brain wave patterns; the client can have the entire meal except for the coffee. The client does not need to be on a liquid diet or NPO.
 
Question 30.
The client is scheduled to receive phenytoin through a nasogastric tube and has a tube-feeding supplement running continuously. The head of the bed is elevated to 30 degrees. Prior to administering the medication, what should the nurse do?
(a) Elevate the head of the bed to 60 degrees.
(b) Draw blood to determine the phenytoin level after giving the morning dose in order to determine if the client has a toxic blood level.
(c) Stop the tube feeding 1 hour before giving phenytoin, and hold tube feeding for 1 hour after giving the medication.
(d) Flush the NGT with 150 mL of water before and after giving the phenytoin.
Answer:
(c) Stop the tube feeding 1 hour before giving phenytoin, and hold tube feeding for 1 hour after giving the medication.

Explanation:
In order for phenytoin to be properly absorbed and provide maximum benefit to the client, nutritional supplements must be stopped before and after delivery. The head of the bed is elevated 30 degrees since this client has a tube feeding infusing; it is not necessary to elevate the bed any further. Blood levels are usually drawn before giving a dose of phenytoin, not after. It is not necessary to flush with such a large amount of water (150 mL) before and after administering phenytoin.
 
Question 31.
Which instruction should the nurse include in the teaching plan for a client with seizures who is going home with a prescription for gabapentin?
(a) Take all the medication until it is gone.
(b) Notify the health care provider (HCP) if vision changes occur.
(c) Store gabapentin in the refrigerator.
(d) Take gabapentin with an antacid to protect against ulcers.
Answer:
(b) Notify the health care provider (HCP) if vision changes occur.

Explanation:
Gabapentin may impair vision. Changes in vision, concentration, or coordination should be reported to the HCP [T]. Gabapentin should not be stopped abruptly because of the potential for status epilepticus; this is a medication that must be tapered off. Gabapentin is to be stored at room temperature and out of direct light. It should not be taken with antacids.
 
Question 32.
What is the priority nursing intervention in the postictal phase of a seizure?
(a) Reorient the client to time, person, and place.
(b) Determine the client’s level of sleepiness.
(c) Assess the client’s breathing pattern.
(d) Position the client comfortably.
Answer:
(c) Assess the client’s breathing pattern.

What is the priority nursing intervention in the postictal phase of a seizure

Explanation:
A priority for the client in the postictal phase (after a seizure) is to assess the client’s breathing pattern for effective rate, rhythm, and depth. The nurse should apply oxygen and ventilation to the client as appropriate. Other interventions, to be completed after the airway has been established, include reorientation of the client to time, person, and place. Determining the client’s level of sleepiness is useful, but it is not a priority. Positioning the client comfortably promotes rest but is of less importance than ascertaining that the airway is patent.
 
Question 33.
Which intervention is most effective in minimizing the risk of seizure activity in a client who is undergoing diagnostic studies after having experienced several episodes of seizures?
(a) Maintain the client on bed rest.
(b) Administer a sedative as prescribed.
(c) Close the door to the room to minimize stimulation.
(d) Administer carbamazepine 200 mg PO, twice per day.
Answer:
(d) Administer carbamazepine 200 mg PO, twice per day.

Explanation:
Carbamazepine is an anticonvulsant that helps prevent further seizures and is the most effective intervention for preventing seizure risk while the client is undergoing diagnostic tests for seizures. Bed rest, sedation, and providing privacy do not minimize the risk of seizures.
 
Question 34.    
What nursing assessments should be documented at the beginning of the ictal phase of a seizure?
(a) heart rate, respirations, pulse oximeter, and blood pressure
(b) last dose of anticonvulsant and circumstances at the time
(c) type of visual, auditory, and olfactory aura the client experienced
(d) movement of the head and eyes and muscle rigidity
Answer:
(d) movement of the head and eyes and muscle rigidity

Explanation:
During a seizure, the nurse should note movement of the client’s head and eyes and muscle rigidity, especially when the seizure first begins, to obtain clues about the location of the trigger focus in the brain. Other important assessments would include noting the progression and duration of the seizure, respiratory status, loss of consciousness, pupil size, and incontinence of urine and stool.

It is typically not possible to assess the client’s pulse and blood pressure during a tonic-clonic seizure because the muscle contractions make assessment difficult to impossible. The last dose of anticonvulsant medication can be evaluated later. The nurse should focus on maintaining an open airway, preventing injury to the client, and assessing the onset and progression of the seizure to determine the type of brain activity involved. The type of aura should be assessed in the preictal phase of the seizure.
 
Question 35.
The nurse is assessing a client in the postictal phase of generalized tonic-clonic seizure. The nurse should determine if the client has which symptom following the seizure?
(a) drowsiness
(b) inability to move
(c) paresthesia
(d) hypotension
Answer:
(a) drowsiness

Explanation:
The nurse should expect a client in the postictal phase to experience drowsiness to somnolence because exhaustion results from the abnormal spontaneous neuron firing and tonic- clonic motor response. An inability to move a muscle part is not expected after a tonic-clonic seizure because a lack of motor function would be related to a complication, such as a lesion, tumor, or stroke, in the correlating brain tissue. A change in sensation would not be expected because this would indicate a complication such as an injury to the peripheral nerve pathway to the corresponding part from the central nervous system. Hypotension is not typically a problem after a seizure.
 
Question 36. 
The health care provider has prescribed phenytoin sodium therapy for a client with seizures. What should the nurse explain to the client about stopping the drug suddenly?
(a) Physical dependency develops over time.
(b) Status epilepticus may occur.
(c) A hypoglycemic reaction is likely.
(d) Heart block can happen.
Answer:
(b) Status epilepticus may occur.

Explanation:
Anticonvulsant drug therapy should never be stopped suddenly; doing so can lead to life-threatening status epilepticus. Phenytoin sodium does not carry a risk of physical dependency or lead to hypoglycemia. Phenytoin has antiarrhyth- mic properties, and discontinuation does not cause heart block.
 
Question 37.
The nurse is teaching a client with seizures to recognize an aura. What should the nurse instruct the client to notice as an onset of an aura?
(a) a postictal state of amnesia
(b) a hallucination that occurs during a seizure
(c) a symptom that occurs just before a seizure
(d) a feeling of relaxation as the seizure begins to subside
Answer:
(c) a symptom that occurs just before a seizure

Explanation:
An aura is a premonition of an impending seizure. Auras usually are of a sensory nature (e.g., an olfactory, visual, gustatory, or auditory sensation); some may be of a psychic nature. Evaluating an aura may help identify the area of the brain from which the seizure originates. Auras occur before a seizure, not during or after (postictal). They are not similar to hallucinations or amnesia or related to relaxation.
 
Question 38.
Which statement by a client with a seizure disorder who has been prescribed topiramate indicates the client has understood the nurse’s instruction about this drug?
(a) “I will take the medicine before going to bed.”
(b) “I will drink six to eight glasses of water a day.”
(c) “I will eat plenty of fresh fruits.”
(d) “I will take the medicine with a meal or snack.”
Answer:
(b) “I will drink six to eight glasses of water a day.”

Explanation:
Toxic effects of topiramate include nephrolithiasis, and clients are encouraged to drink six to eight glasses of water a day to dilute the urine and flush the renal tubules to avoid stone formation. Topiramate is taken in divided doses because it produces drowsiness. Although eating fresh fruits is desirable from a nutritional standpoint, this is not related to the topiramate. The drug does not have to be taken with meals.
 
Question 39.    
Which clinical manifestation is a typical reaction to long-term phenytoin sodium therapy?
(a) weight gain
(b) insomnia
(c) excessive growth of gum tissue
(d) deteriorating eyesight
Answer:
(c) excessive growth of gum tissue

Explanation:
A common adverse effect of long-term phenytoin therapy is an overgrowth of gingival tissues. Problems may be minimized with good oral hygiene, but in some cases, overgrown tissues must be removed surgically. Phenytoin does not cause weight gain, insomnia, or deteriorating eyesight.
 
Question 40.    
A 21-year-old female client takes clonazepam. What should the nurse ask this client about? Select all that apply.
(a) seizure activity
(b) pregnancy status
(c) alcohol use
(d) cigarette smoking
(e) intake of caffeine and sugary drinks
Answer:
(a) seizure activity
(b) pregnancy status
(c) alcohol use

Explanation:
(a), (b), (c). The nurse should assess the number and type of seizures the client has experienced since starting clonazepam monotherapy for seizure control. The nurse should also determine if the client might be pregnant because clonazepam crosses the placental barrier. The nurse should also ask about the client’s use of alcohol because alcohol potentiates the action of clonazepam. Although the nurse may want to check on the client’s diet or use of cigarettes for health maintenance and promotion, such information is not specifically related to clonazepam therapy.
 
Question 41. 
Which outcomes indicate effective management of a conscious client who is being treated with recombinant tissue plasminogen therapy during the initial phase of an ischemic cerebral vascular accident (CVA)? Select all that apply.
(a) headache reduced
(b) dysphagia improved
(c) visual disturbances improved
(d) responds to comfort measures
(e) no signs or symptoms of bleeding
Answer:
(a) headache reduced
(d) responds to comfort measures
(e) no signs or symptoms of bleeding

Explanation:
(a), (d), (e). A headache (which is treated with analgesics) is commonly associated with an ischemic CVA.  A conscious client responds to comfort measures. Bleeding is a side effect of recombinant tissue plasminogen (t-PA) therapy to dissolve the clots; absence of bleeding is a desired outcome. Reduction of dysphagia and visual disturbances is unpredictable and less likely to occur during this phase.
 
Question 42. 
A client admitted with possible ischemic stroke has been aphasic for 3 hours and has a blood pressure (BP) of 220/120 mm Hg. Which prescription by the health care provider should the nurse question?
(a) labetalol drip to keep the blood pressure <120/80 mm Hg
(b) tissue plasminogen activator (tPA) per protocol
(c) normal saline intravenously at 75 mL/h
(d) bed elevated 30 degrees
Answer:
(a) labetalol drip to keep the blood pressure <120/80 mm Hg

Explanation:
The nurse should question the prescription to administer labetalol to decrease the blood pressure to <20/80 mm Hg. It is not recommended that diastolic blood pressure is <90 mm Hg. Mean arterial pressure (MAP) should be kept between 80 and 110 mm Hg. The client’s presenting BP is 220/120 mm Hg, which would indicate a MAP of 146. When a client has a stroke, autoregulation is a protective mechanism use to protect the brain.

An elevated blood pressure helps to increase cerebral perfusion. The standard of care is to administer tissue plasminogen activator (tPA) within 4.5 hours of signs and symptoms of a stroke. Normal saline is an isotonic solution recommended for a client experiencing an ischemic stroke. Keeping the head of the bed at 30 degrees helps to decrease intracranial pressure.

Question 43.
Following a stroke, a client has dysphagia and left-sided facial paralysis. Which feeding technique will be most helpful at this time?
(a) Encourage sipping diluted liquid meal supplements from a straw.
(b) Position the client with the bed at a 30-degree angle.
(c) Offer solid foods from the unaffected side of the mouth.
(d) Feed the client a soft diet from a spoon into the left side of the mouth.
Answer:
(c) Offer solid foods from the unaffected side of the mouth.

Explanation:
Following a stroke, it is easiest for clients with dysphagia (difficulty swallowing) to swallow solid foods; the nurse introduces foods on the unaffected side. Liquid foods are difficult to swallow, and the client with facial paralysis will have difficulty sipping using a straw. The head of the bed is elevated to 90 degrees, or the client is instructed to sit up, if possible, while eating to prevent choking and aspiration.
 
Question 44.    
A client is being monitored for transient ischemic attacks. The client is oriented, can open the eyes spontaneously, and follows commands. What is the Glasgow Coma Scale score?
Glasgow Coma Scale

Parameter

Finding

Score

Eye opening

Spontaneously

4

To speech

3

To pain

2

Do not open

1

Best verbal response

Oriented

5

Confused

4

Inappropriate speech

3

Incomprehensible sounds

2

No verbalization

1

Best motor response

Obeys command

6

Localizes pain

5

Withdraws from pain

4

Abnormal flexion

3

Abnormal extension

2

No motor response

1

Interpretation: Best score = 15; worst score = 3; 7 or less generally indicates coma; changes from baseline are most important.
Answer:
15 points

Explanation:
The Glasgow Coma Scale provides three objective neurologic assessments: spontaneity of eye opening, best motor response, and best verbal response on a scale of 3 to 15. The client who scores the best on all three assessments scores 15 points.

Question 45. 
The nurse is teaching a client about taking prophylactic warfarin sodium. Which statement indicates that the client understands how to take the drug? Select all that apply.
(a) “The drug’s action peaks in 2 hours.”
(b) “Maximum dosage is not achieved until 3 to 4 days after starting the medication.”
(c) “Effects of the drug continue for 4 to 5 days after discontinuing the medication.”
(d) “Protamine sulfate is the antidote for warfarin.”
(e) “I should have my blood levels tested periodically.”
Answer:
(b) “Maximum dosage is not achieved until 3 to 4 days after starting the medication.”
(c) “Effects of the drug continue for 4 to 5 days after discontinuing the medication.”
(e) “I should have my blood levels tested periodically.”

Explanation:
(b), (c),(e). The maximum dosage of warfarin sodium is not achieved until 3 to 4 days after starting the medication, and the effects of the drug continue for 4 to 5 days after discontinuing the medication. The client should have blood levels tested periodically to make sure that the desired level is maintained. Warfarin has a peak action of 9 hours. Vitamin K is the antidote for warfarin; protamine sulfate is the antidote for heparin.
  
Question 46.    
The nurse is observing the unlicensed assistive personnel (UAP) give mouth care to a client who has had a stroke and is unconscious. The nurse should intervene if the UAP does which?
(a) positions the client on the back with a small pillow under the head
(b) keeps portable suctioning equipment at the bedside
(c) opens the client’s mouth with a padded tongue blade
(d) cleans the client’s mouth and teeth with a toothbrush
Answer:
(a) positions the client on the back with a small pillow under the head

Explanation:
The UAP should position an unconscious client on the side, not on the back, with the head on a small pillow. A lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration. It may be necessary to suction the client if he or she aspirates. Suction equipment should be nearby. It is safe to use a padded tongue blade, and the client should receive oral care, including brushing with a toothbrush.
  
Question 47.    
A client arrives in the emergency department with an ischemic stroke. What should the nurse do before the client receives tissue plasminogen activator (t-PA)?
(a) Ask what medications the client is taking.
(b) Complete a history and health assessment.
(c) Identify the time of onset of the stroke.
(d) Determine if the client is scheduled for any surgical procedures.
Answer:
(c) Identify the time of onset of the stroke.

Explanation:
Studies show that clients who receive recombinant t-PA treatment within 3 hours after the onset of a stroke have better outcomes. The time from the onset of a stroke to t-PA treatment is critical. A complete health assessment and history is not possible when a client is receiving emergency care.

Upcoming surgical procedures may need to be delayed because of the administration of t-PA, which is a priority in the immediate treatment of the current stroke. While the nurse should identify which medications the client is taking, it is more important to know the time of the onset of the stroke to determine the course of action for administering tPA.

Question 48.    
A client has received thrombolytic treatment for an ischemic stroke. The nurse should notify the health care provider (HCP) if there is a rapid increase in which vital signs?
(a) pulse
(b) respirations
(c) blood pressure
(d) temperature
Answer:
(c) blood pressure

A client has received thrombolytic treatment for an ischemic stroke. the nurse should notify the health care provider

Explanation:
Control of blood pressure is critical during the first 24 hours after treatment because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Vital signs are monitored, and blood pressure is maintained as identified by the health care provider (HCP) and specific to the client’s ischemic tissue needs and risk of bleeding from treatment. The other vital signs are important, but the priority is to monitor blood pressure.
  
Question 49.    
What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?
(a) cholesterol level
(b) pupil size and pupillary response
(c) bowel sounds
(d) echocardiogram
Answer:
(b) pupil size and pupillary response

Explanation:
It is crucial to monitor the pupil size and pupillary response to indicate changes around the cranial nerves. The cholesterol level is not a priority assessment, although it may be an assessment to be addressed for long-term healthy lifestyle rehabilitation. Bowel sounds need to be assessed because an ileus or constipation can develop, but this is not a priority in the first 24 hours when the primary concerns are cerebral hemorrhage and increased intracranial pressure. An echocardiogram is not needed for the client with a thrombotic stroke without heart problems.
  
Question 50.    
A client with a hemorrhagic stroke is slightly agitated, heart rate is 118 bpm, respirations are 22 breaths/min, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88 mm Hg, and oral secretions are noted. What order of interventions from first to last should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion? All options must be used.
(a) Suction the airway.
(b) Hyperoxygenate. 
(c) Suction the mouth.
(d) Provide sedation.
Answer:
(d) Provide sedation.
(b) Hyperoxygenate.
(a) Suction the airway.
(c) Suction the mouth.

Explanation:
(d), (b), (a), (c). Increased agitation with suctioning will increase ICP; therefore, sedation should be provided first. The client should be hyperoxygenated before and after suctioning to prevent hypoxia since hypoxia causes vasodilation of the cerebral vessels and increases ICP. The airway should then be suctioned for no more than 10 seconds. The mouth can be suctioned once the airway is clear to remove oral secretions. Once the mouth is suctioned, the suction catheter should be discarded.

Question 51.
The nurse is developing a care plan for a client who has had a stroke. The nurse asks about the client’s functional status before the stroke. How will the nurse incorporate this information into the care plan?
The client’s functional status before the stroke will:
(a) guide the rehabilitation plan.
(b) help predict outcomes.
(c) help the client recognize physical limitations.
(d) determine if the client can be expected to regain most functional status.
Answer:
(a) guide the rehabilitation plan.

Explanation:
The primary reason for the nursing assessment of a client’s functional status before the stroke is to guide the rehabilitation plan. The assessment does not help to predict how far the rehabilitation team can help the client to recover from the residual effects of the stroke, only what plans can help a client who has moved from one functional level to another. The nursing assessment of the client’s functional status does not help the client recognize limitations

Question 52.
Which positioning technique is most effective when there is only one person to assist the client in moving from the left side to the right side if the client has hemiparalysis?
(a) rolling the client onto the side
(b) sliding the client to move up in bed
(c) lifting the client when moving the client up in bed
(d) having the client help lift off the bed using a trapeze
Answer:
(a) rolling the client onto the side

Explanation:
Rolling the client is the most effective method to use when there is only one person to help the client change positions from one side to another. The nurse must keep the client in anatomically neutral positions and ensure that the limbs are properly supported. Sliding a client on a sheet causes friction and is to be avoided. Friction injures skin and predisposes to pressure ulcer formation. The client may be lifted as long as the nurse has assistance and uses proper body mechanics to avoid injury. Having the client lift off the bed with a trapeze is an acceptable means to move a client when the client needs to use the bedpan or lie on the back.
   
Question 53. 
The nurse is caring for a client who is paraplegic as a result of a stroke. At home, the client uses a wheelchair for mobility and can transfer independently. The client is now being treated with IV antibiotics for a sacral wound via a peripherally inserted central catheter. The client is alert and oriented and has no previous history of falling. Using the Morse Fall Scale (see exhibit), what is this client’s total score? 

Item

Scale

Scoring

1. History of falling; immediate or within 3 months

No          0

Yes         25

 

2. Secondary diagnosis

No          0

Yes         15

 

3. Ambulatory aid Bed rest/nurse assist Crutches/cane/walker Furniture

                0

                15

                30

 

4. IV/Heparin Lock

No          0

Yes         20

 

5. Gait/Transferring Normal/bedrest/immobile Weak Impaired

                0

                10

                20

 

6. Mental status Oriented to own ability Forgets limitations

                0

                15

 

Answer:
35.

Explanation:
This client has a fall risk score of 35 and is at medium fall risk due to the client’s secondary diagnosis (15) and IV access (20). Though paraplegic, this does not affect the client’s fall risk assessment as the client will be either in bed or in a wheelchair; the client therefore is not assessed points on the fall risk for “ambulatory aid” or “gait.”

Question 54.
Which is the most effective means of pre-venting plantar flexion in a client who has had a stroke with residual paralysis?
(a) Place the client’s feet against a firm footboard.
(b) Reposition the client every 2 hours.
(c) Have the client wear ankle-high tennis shoes at intervals throughout the day.
(d) Massage the client’s feet and ankles regularly.
Answer:
(c) Have the client wear ankle-high tennis shoes at intervals throughout the day.

Explanation:
The use of ankle-high tennis shoes has been found to be most effective in preventing plantar flexion (footdrop) because they add support to the foot and keep it in the correct anatomic position. Footboards stimulate spasms and are not routinely recommended. Regular repositioning and range-of-motion exercises are important interventions, but the client’s foot needs to be in the correct anatomic position to prevent overextension of the muscle and tendon. Massaging does not prevent plantar flexion and, if rigorous, could release emboli.
   
Question 55. 
The nurse is planning the care of a hemiplegic client to prevent joint deformities of the arm and hand. Which position is appropriate? Select all that apply.
(a) placing a pillow in the axilla so the arm is away from the body
(b) inserting a pillow under the slightly flexed arm so the hand is higher than the elbow
(c) immobilizing the extremity in a sling
(d) positioning a hand cone in the hand so the fingers are barely flexed
(e) keeping the arm at the side using a pillow
Answer:
(a) placing a pillow in the axilla so the arm is away from the body
(b) inserting a pillow under the slightly flexed arm so the hand is higher than the elbow
(d) positioning a hand cone in the hand so the fingers are barely flexed

Explanation:
(a), (b), (d). Placing a pillow in the axilla so the arm is away from the body keeps the arm abducted and prevents skin from touching skin to avoid skin breakdown. Placing a pillow under the slightly flexed arm so the hand is higher than the elbow prevents dependent edema. Positioning a hand cone (not a rolled washcloth) in the hand prevents hand contractures. Immobilization of the extremity may cause a painful shoulder-hand syndrome. Flexion contrac-tures of the hand, wrist, and elbow can result from immobility of the weak or paralyzed extremity. It is better to extend the arms to prevent contractures.
   
Question 56.    
For the client who is experiencing expressive aphasia, which nursing intervention is most helpful in promoting communication?
(a) speaking loudly and slowly
(b) using a “picture board” for the client to point to pictures
(c) writing directions so the client can read them
(d) speaking in short sentences
Answer:
(b) using a “picture board” for the client to point to pictures

Explanation:
Expressive aphasia is a condition in which the client understands what is heard or written but cannot say what he or she wants to say. A communication or picture board helps the client communicate with others in that the client can point to objects or activities that he or she desires. Receptive aphasia is a condition in which the client does not comprehend what is being said. For this client, it is helpful to speak clearly using short sentences or writing out directions.
   
Question 57.    
The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. Which strategies should the nurse include in the teaching plan? Select all that apply.
(a) maintaining an upright position while eating
(b) restricting the diet to liquids until swallowing improves
(c) introducing foods on the unaffected side of the mouth
(d) keeping distractions to a minimum
(e) cutting food into large pieces of finger food
Answer:
(a) maintaining an upright position while eating
(c) introducing foods on the unaffected side of the mouth
(d) keeping distractions to a minimum

Explanation:
(a), (c), (d). A client with dysphagia (difficulty swallowing) commonly has the most difficulty ingesting thin liquids, which are easily aspirated. Liquids should be thickened to avoid aspiration. Maintaining an upright position while eating is appropriate because it minimizes the risk of aspiration. Introducing foods on the unaffected side I allows the client to have better control over the food bolus. The client should concentrate on chewing and swallowing; therefore, distractions should be avoided. Large pieces of food could cause choking; the food should be cut into bite-sized pieces.
   
Question 58.    
The nurse is assisting a client with a stroke who has homonymous hemianopia. The nurse should understand that the client will do which when eating?
(a) Have a preference for foods high in salt.
(b) Eat food on only half of the plate.
(c) Forget the names of foods.
(d) Be unable to swallow liquids.
Answer:
(b) Eat food on only half of the plate.

Explanation:
Homonymous hemianopia is blindness in half of the visual field; therefore, the client would see only half of the plate. Eating only the food on half of the plate results from an inability to coordinate visual images and spatial relationships. There may be an increased preference for foods high in salt after a stroke, but this would not be related to homonymous hemianopia. Forgetting the names of foods is a sign of aphasia, which involves a cerebral cortex lesion. Being unable to swallow liquids is dysphagia, which involves motor pathways of cranial nerves IX and X, including the lower brain stem.
   
Question 59.    
A nurse is teaching a client who had a stroke about ways to adapt to a visual disability. Which does the nurse identify as the primary safety precaution to use?
(a) Wear a patch over one eye.
(b) Place personal items on the sighted side.
(c) Lie in bed with the unaffected side toward the door.
(d) Turn the head from side to side when walking.
Answer:
(d) Turn the head from side to side when walking.

Explanation:
To expand the visual field, the partially sighted client should be taught to turn the head from side to side when walking. Neglecting to do so may result in accidents. This technique helps maximize the use of remaining sight. Covering an eye with a patch will limit the field of vision. Personal items can be placed within sight and reach, but most accidents occur from tripping over items that cannot be seen. It may help the client to see the door, but walking presents the primary safety hazard.
   
Question 60.    
A client is experiencing mood swings after a stroke and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct family members to try when the client experiences a crying episode?
(a) Sit quietly with the client until the episode is over.
(b) Ignore the behavior.
(c) Attempt to divert the client’s attention.
(d) Tell the client that this behavior is unacceptable.
Answer:
(c) Attempt to divert the client’s attention.

Explanation:
A client who has brain damage may be emotionally labile and may cry or laugh for no explainable reason. Crying is best dealt with by attempting to divert the client’s attention. Ignoring the behavior will not affect the mood swing or the crying and may increase the client’s sense of isolation. Telling the client to stop is inappropriate.

Herbs & Spices That Boost Brain 
   
Question 61. 
When communicating with a client who has aphasia, which approaches are helpful? Select all that apply.
(a) Present one thought at a time.
(b) Avoid writing messages.
(c) Speak with normal volume.
(d) Make use of gestures.
(e) Encourage pointing to the needed object.
Answer:
(a) Present one thought at a time.
(c) Speak with normal volume.
(d) Make use of gestures.
(e) Encourage pointing to the needed object.

Explanation:
(a), (c), (d), (e). The goal of communicating with a client with aphasia is to minimize frustration and exhaustion. The nurse should encourage the client to write messages or use alternative forms of communication to avoid frustration. Presenting one thought at a time decreases stimuli that may distract the client, as does speaking in a normal volume and tone. The nurse should ask the client to point to objects and encourage the use of gestures to assist in communicating.
   
Question 62.
What is the expected outcome of thrombolytic drug therapy for stroke?
(a) increased vascular permeability
(b) vasoconstriction
(c) dissolved emboli
(d) prevention of hemorrhage
Answer:
(c) dissolved emboli

Explanation:
Thrombolytic enzyme agents are used for clients with a thrombotic stroke to dissolve emboli, thus reestablishing cerebral perfusion. They do not increase vascular permeability, cause vasoconstriction, or prevent further hemorrhage.
   
Question 63.
Which nursing approach is most helpful to a client with Parkinson’s disease who is experiencing a freezing of gait with difficulty initiating movement?
(a) Pull the client forward to initiate walking.
(b) Instruct the client to use a wheelchair.
(c) Have the client remain still.
(d) Tell the client to march in place.
Answer:
(d) Tell the client to march in place.

Explanation:
When a freezing gait occurs, having the client march in place or step over actual lines, imaginary lines, or objects on the floor can promote walking. Instructing the client to take one step backward and two steps forward may also stimulate walking. Pulling the client forward can cause imbalance. The nurse does not instruct the client to use a wheelchair. The client obtains much exercise as possible; having the client remain still does not help the client obtain the momentum needed to walk.
   
Question 64.    
A health care provider (HCP) has prescribed carbidopa-levodopa four times per day for a client with Parkinson’s disease. The client wants “to end it all now that the Parkinson’s disease has progressed.” What should the nurse do? Select all that apply.
(a) Explain that the new prescription for carbidopa-levodopa will treat the depression.
(b) Encourage the client to discuss feelings as the carbidopa-levodopa is being administered.
(c) Contact the HCP before administering the carbidopa-levodopa.
(d) Determine if the client is on antidepressants or monoamine oxidase (MAO) inhibitors.
(e) Determine if the client is at risk for suicide.
Answer:
(c) Contact the HCP before administering the carbidopa-levodopa.
(d) Determine if the client is on antidepressants or monoamine oxidase (MAO) inhibitors.
(e) Determine if the client is at risk for suicide.

Explanation:
(c), (d), (e). The nurse should contact the HCP CXI before administering carbidopa-levodopa because this medication can cause further symptoms of depression. Suicide threats in clients with chronic illness should be taken seriously. The nurse should also determine if the client is on an MAO inhibitor because concurrent use with carbidopa-levodopa can cause a hypertensive crisis. Carbidopa-levodopa is not a treatment for depression. Having the client discuss feelings is appropriate when the prescription is finalized.
   
Question 65. 
Which is an initial sign of Parkinson’s disease?
(a) rigidity
(b) tremor
(c) bradykinesia
(d) akinesia
Answer:
(b) tremor

Explanation:
The first sign of Parkinson’s disease is usually tremors. The client commonly is the first to notice this sign because the tremors may be minimal at first. Rigidity is the second sign, and bradyki- nesia is the third sign. Akinesia is a later stage of bradykinesia.
   
Question 66.
The nurse develops a teaching plan for a client newly diagnosed with Parkinson’s disease. Which topic is most important to include in the plan?
(a) maintaining a balanced nutritional diet
(b) enhancing the immune system
(c) maintaining a safe environment
(d) engaging in diversional activity
Answer:
(c) maintaining a safe environment

Explanation:
The primary focus is on maintaining a safe environment because the client with Parkinson’s disease usually has a propulsive gait, characterized by a tendency to take increasingly quicker steps while walking. This type of gait commonly causes the client to fall or to have trouble stopping. The client should maintain a balanced diet, enhance the immune system, and enjoy diversional activities; however, safety is the primary concern.
   
Question 67.    
The nurse observes that when a client with Parkinson’s disease unbuttons her shirt, the upper arm tremors disappear. Which statement best guides the nurse’s analysis of this observation about the client’s tremors?
(a) The tremors are probably psychological and can be controlled at will.
(b) The tremors sometimes disappear with purposeful and voluntary movements.
(c) The tremors disappear when the client’s attention is diverted by some activity.
(d) There is no explanation for the observation; it is a chance occurrence.
Answer:
(b) The tremors sometimes disappear with purposeful and voluntary movements.

Explanation:
Voluntary and purposeful movements often temporarily decrease or stop the tremors associated with Parkinson’s disease. In some clients, however, tremors may increase with voluntary effort. Tremors associated with Parkinson’s disease are not psychogenic but are related to an imbalance between dopamine and acetylcholine. Tremors cannot be reduced by distracting the client.
   
Question 68.    
At what time of day should the nurse encourage a client with Parkinson’s disease to schedule the most demanding physical activities to minimize the effects of hypokinesia?
(a) early in the morning, when the client’s energy level is high
(b) to coincide with the peak action of drug therapy
(c) immediately after a rest period
(d) when family members will be available
Answer:
(b) to coincide with the peak action of drug therapy

Explanation:
Demanding physical activity should be performed during the peak action of drug therapy. Clients should be encouraged to maintain independence in self-care activities to the greatest extent possible. Although some clients may have more energy in the morning or after rest, tremors are man-aged with drug therapy.
   
Question 69.    
Which goal is the most realistic for a client diagnosed with Parkinson’s disease?
(a) to cure the disease
(b) to stop progression of the disease
(c) to begin preparations for terminal care
(d) to maintain optimal body function
Answer:
(d) to maintain optimal body function

Explanation:
Helping the client function at his or her best is most appropriate and realistic. There is no known cure for Parkinson’s disease. Parkinson’s disease progresses in severity, and there is no known way to stop its progression. However, many clients live for years with the disease, and it would not be appropriate to start planning terminal care at this time.
   
Question 70.    
Which goal is collaboratively established by the client with Parkinson’s disease, the nurse, and the physical therapist?
(a) to maintain joint flexibility
(b) to build muscle strength
(c) to improve muscle endurance
(d) to reduce ataxia
Answer:
(a) to maintain joint flexibility

Explanation:
The primary goal of physical therapy and nursing interventions is to maintain joint flexibility and muscle strength. Parkinson’s disease involves a degeneration of dopamine-producing neurons; therefore, it would be an unrealistic goal to attempt to build muscles or increase endurance. The decrease in dopamine neurotransmitters results in ataxia secondary to extrapyramidal motor system effects. Attempts to reduce ataxia through physical therapy would not be effective.
   
Question 71.
A client with Parkinson’s disease is prescribed levodopa (L-dopa) therapy. Improvement in which area indicates effective therapy?
(a) mood
(b) muscle rigidity 
(c) appetite
(d) alertness
Answer:
(b) muscle rigidity 

Explanation:
Levodopa is prescribed to decrease severe muscle rigidity. Levodopa does not improve mood, appetite, or alertness in a client with Parkinson’s disease.
   
Question 72.
A client is being switched from levodopa (L-dopa) to carbidopa-levodopa. The nurse should monitor for which possible complication during medication changes and dosage adjustment?
(a) euphoria
(b) jaundice
(c) vital sign fluctuation
(d) signs and symptoms of diabetes
Answer:
(c) vital sign fluctuation

Explanation:
Vital signs should be monitored, especially during periods of adjustment. Changes, such as orthostatic hypotension, cardiac irregularities, palpitations, and light-headedness, should be reported immediately. The client may actually experience suicidal or paranoid ideation instead of euphoria.

The nurse should monitor the client for elevated liver enzyme levels, such as lactate dehydrogenase, aspartate aminotransferase, alanine aminotransferase, blood urea nitrogen, and alkaline phosphatase, but the client should not be jaundiced. The client should not experience signs and symptoms of diabetes or a low serum glucose level, but the nurse should check the hemoglobin and hematocrit levels.
   
Question 73.    
A client with Parkinson’s disease needs a long time to complete morning care but becomes annoyed when the nurse offers assistance and refuses all help. Which action is the nurse’s best initial response in this situation?
(a) Tell the client firmly that he or she needs assistance and help with the morning care.
(b) Praise the client for the desire to be independent and give extra time and encouragement.
(c) Tell the client that he or she is being unrealistic about the abilities and must accept the fact that he or she needs help.
(d) Suggest to the client to at least modify the morning care routine if he or she insists on self-care.
Answer:
(b) Praise the client for the desire to be independent and give extra time and encouragement.

Explanation:
Ongoing self-care is a major focus for clients with Parkinson’s disease. The client should be given additional time as needed and praised for efforts to remain independent. Firmly telling the client that he or she needs assistance will undermine self-esteem and defeat efforts to be independent. Telling the client that perception of the situation is unrealistic does not foster hope in the ability to perform self-care measures. Suggesting that the client modify the morning routine seems to put the hospital or the nurse’s time schedule before the client’s needs. This will only decrease the client’s selfesteem and the desire to try to continue self-care, which is obviously important to the client.
  
Question 74.    
Which is an expected outcome for a client with Parkinson’s disease who has had a pallidotomy?
(a) improved functional ability
(b) reduced emotional stress
(c) increased alertness
(d) better appetite
Answer:
(a) improved functional ability

Explanation:
The goal of a pallidotomy is to improve functional ability for the client with Parkinson’s disease. This is a priority. The pallidotomy creates lesions in the globus pallidus to control extrapyramidal disorders that affect control of movement and gait. If functional ability is improved by the pallidot-omy, the client may experience a secondary response of an improved emotional response, but this is not the primary goal of the surgical procedure. The procedure will not improve alertness or appetite.
   
Question 75. 
When assessing the client with multiple sclerosis for potential complications of the disease, the nurse should asses the client for which symptoms? Select all that apply.
(a) dehydration
(b) falls
(c) seizures
(d) skin breakdown
(e) fatigue
Answer:
(b) falls
(d) skin breakdown
(e) fatigue

Explanation:
(b), (d), (e). The client with multiple sclerosis is at risk for falls due to muscle weakness, skin breakdown due to bowel and bladder incontinence, and fatigue. The client is not at risk for dehydration; seizures are not associated with myelin destruction.
   
Question 76. 
The nurse is teaching a client with bladder dysfunction from multiple sclerosis (MS) about bladder training at home. Which instructions should the nurse include in the teaching plan? Select all that apply.
(a) Restrict fluids to 1,000 mL/24 hours.
(b) Drink 400 to 500 mL with each meal.
(c) Drink fluids midmorning, midafternoon, and late afternoon.
(d) Attempt to void at least every 2 hours.
(e) Use intermittent catheterization as needed.
Answer:
(b) Drink 400 to 500 mL with each meal.
(c) Drink fluids midmorning, midafternoon, and late afternoon.
(d) Attempt to void at least every 2 hours.
(e) Use intermittent catheterization as needed.

Explanation:
(b), (c), (d), (e). Maintaining urinary function in a client with neurogenic bladder dysfunction from MS is an important goal. The client should ideally drink 400 to 500 ml with each meal; drink 200 mL midmorning, midafternoon, and late afternoon; and attempt to void at least every 2 hours to prevent infection and stone formation. The client may need to catheterize herself to drain residual urine in the bladder. Restricting fluids during the day will not produce sufficient urine. However, in bladder training for nighttime continence, the client may restrict fluids for 1 to 2 hours before going to bed. The client should drink at least 2,000 mL every 24 hours.
   
Question 77.
Which is not a typical clinical manifestation of multiple sclerosis (MS)?
(a) double vision
(b) sudden bursts of energy
(c) weakness in the extremities
(d) muscle tremors
Answer:
(b) sudden bursts of energy

Explanation:
With MS, hyperexcitability and euphoria may occur, but because of muscle weakness, sudden bursts of energy are unlikely. Visual disturbances, weakness in the extremities, and loss of muscle tone and tremors are common symptoms of MS.
   
Question 78.    
A client with multiple sclerosis (MS) is receiving baclofen. The nurse determines that the drug is effective when it produces which outcome?
(a) induces sleep
(b) stimulates the client’s appetite
(c) relieves muscular spasticity
(d) reduces the urine bacterial count
Answer:
(c) relieves muscular spasticity

Explanation:
Baclofen is a centrally acting skeletal muscle relaxant that helps relieve the muscle spasms common in MS. Drowsiness is an adverse effect, and driving should be avoided if the medication produces a sedative effect. Baclofen does not stimulate the appetite or reduce bacteria in the urine.
   
Question 79.    
A client has had multiple sclerosis (MS) for 15 years and has received various drug therapies. What is the primary reason why the nurse has found it difficult to evaluate the effectiveness of the drugs that the client has used?
The client:
(a) exhibits intolerance to many drugs.
(b) experiences spontaneous remissions from time to time.
(c) requires multiple drugs simultaneously.
(d) endures long periods of exacerbation before the illness responds to a particular drug.
Answer:
(b) experiences spontaneous remissions from time to time.

Explanation:
Evaluating drug effectiveness is difficult because a high percentage of clients with MS exhibit unpredictable episodes of remission, exacerbation, and steady progress without apparent cause. Clients with MS do not necessarily have increased intolerance to drugs, nor do they endure long periods of exacerbation before the illness responds to a par-ticular drug. Multiple drug use is not what makes evaluation of drug effectiveness difficult.
   
Question 80.    
When the nurse talks with a client with multiple sclerosis who has slurred speech, which nursing intervention is contraindicated?
(a) encouraging the client to speak slowly
(b) encouraging the client to speak distinctly
(c) asking the client to repeat indistinguishable words
(d) asking the client to speak louder when tired
Answer:
(d) asking the client to speak louder when tired

Explanation:
Asking a client to speak louder even when tired may aggravate the problem. Asking the client to speak slowly and distinctly and to repeat hard-to-understand words helps the client to communicate effectively.

Question 81.
The right hand of a client with multiple sclerosis trembles severely whenever she attempts a voluntary action. She spills her coffee twice at lunch and cannot get her dress fastened securely. Which is the best legal documentation in nurses’ notes of the medical record for this client assessment?
(a) “Has an intention tremor of the right hand.”
(b) “Right-hand tremor worsens with purposeful acts.”
(c) “Needs assistance with dressing and eating due to severe trembling and clumsiness.”
(d) “Slight shaking of right hand increases to severe tremor when a client tries to button her clothes or drink from a cup.”
Answer:
(d) “Slight shaking of right hand increases to severe tremor when a client tries to button her clothes or drink from a cup.”

The right hand of a client with multiple sclerosis trembles severely whenever they attempt a voluntary action

Explanation:
The nurses’ notes should be concise, objective, clearly stated, and relevant. This client trembles when she attempts voluntary actions, such as drinking a beverage or fastening clothing. This activity should be described exactly as it occurs so that others reading the note will have no doubt about the nurse’s observation of the client’s behavior. Identifying the “intentional” activity of daily living will help the interdisciplinary team individualize the client’s plan of care. Clarifying what is meant by “worsening” with a purposeful act will facilitate the interrater reliability of the team. It is better to state what the client did than to give vague nursing orders in the nurses’ notes.
   
Question 82.
A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting
a bowel retraining program. Which strategy is not appropriate?
(a) eating a diet high in fiber
(b) setting a regular time for elimination
(c) using an elevated toilet seat
(d) limiting fluid intake to 1,000 mL/day
Answer:
(d) limiting fluid intake to 1,000 mL/day

Explanation:
Limiting fluid intake is likely to aggravate rather than relieve symptoms when a bowel retraining program is being implemented. Furthermore, water imbalance, as well as electrolyte imbalance, tends to aggravate the signs and symptoms of MS. A diet high in fiber helps keep bowel movements regular. Setting a regular time each day for elimination helps train the body to maintain a schedule. Using an elevated toilet seat facilitates transfer of the client from the wheelchair to the toilet or from a standing to a sitting position.
   
Question 83.
Which nursing goal is realistic to establish with a client who has multiple sclerosis (MS)?
(a) greater joint flexibility
(b) improved muscle strength
(c) clearer thinking
(d) fewer mood swings
Answer:
(b) improved muscle strength

Explanation:
MS is a progressive, chronic neurologic disease characterized by patchy demyelination throughout the central nervous system. This interferes with the transmission of electrical impulses from one nerve cell to the next. Care for the client with MS is directed toward maintaining muscle strength, preventing deformities, preventing and treating depression, and providing client motivation. MS affects speech, coordination, and vision, but not cognition.
   
Question 84.    
The nurse is preparing a client with multiple sclerosis (MS) for discharge from the hospital to home. What information should the nurse include in the teaching plan?
(a) “You’ll need to accept the necessity for a quiet and inactive lifestyle.”
(b) “Keep active, use stress reduction strategies, and avoid fatigue.”
(c) “Follow good health habits to change the course of the disease.”  
(d) “Practice using the mechanical aids that you’ll need when future disabilities arise.”
Answer:
(b) “Keep active, use stress reduction strategies, and avoid fatigue.”

Explanation:
The nurse’s most positive approach is to encourage a client with MS to keep active, use stress reduction strategies, and avoid fatigue because it is important to support the immune system while remaining active. A quiet, inactive lifestyle is not necessarily indicated. Good health habits are not likely to alter the course of the disease, although they may help minimize complications. Practicing using aids that will be needed for future disabilities may be helpful but also can be discouraging.
 
Question 85.    
Which information should the nurse include in the discharge plan for a client with multiple sclerosis who has an impaired peripheral sensation? Select all that apply.
(a) Carefully test the temperature of bath water.
(b) Avoid kitchen activities because of the risk of injury.
(c) Avoid hot water bottles and heating pads.
(d) Inspect the skin daily for injury or pressure points.
(e) Wear warm clothing when outside in cold temperatures.
Answer:
(a) Carefully test the temperature of bath water.
(c) Avoid hot water bottles and heating pads.
(d) Inspect the skin daily for injury or pressure points.
(e) Wear warm clothing when outside in cold temperatures.

Explanation:
(a), (c), (d), (e). A client with impaired peripheral sensation does not feel pain as readily as does someone whose sensation is unimpaired; therefore, water temperatures should be tested carefully. The client should be advised to avoid using hot water bottles or heating pads and to protect against cold temperatures. Because the client cannot rely on minor pain as an indicator of damaged skin or sore spots, the client should carefully inspect the skin daily to visualize any injuries that he or she cannot feel.

The client should not be instructed to avoid kitchen activities out of fear of injury; independence and self-care are also important. However, the client should meet with an occupational therapist to learn about assistive devices and techniques that can reduce injuries, such as burns and cuts that are common in kitchen activities.
   
Question 86.    
Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence?
(a) Limit fluid intake to 1,000 mL/day.
(b) Insert an indwelling urinary catheter.
(c) Establish a regular voiding schedule.
(d) Administer prophylactic antibiotics as prescribed.
Answer:
(c) Establish a regular voiding schedule.

Explanation:
Maintaining a regular voiding pattern is the most appropriate measure to help the client avoid urinary incontinence. Fluid intake is not related to incontinence. Incontinence is related to the strength of the detrusor and urethral sphincter muscles. Inserting an indwelling catheter would be a treatment of last resort because of the increased risk of infection. If catheterization is required, intermittent self-catheterization is preferred because of its lower risk of infection. Antibiotics do not influence urinary incontinence.
   
Question 87.
A client with multiple sclerosis (MS) lives with her daughter and 3-year-old granddaughter. The daughter asks the nurse what she can do at home to help her mother. Which measure would be most beneficial?
(a) psychotherapy 
(b) regular exercise
(c) day care for the granddaughter 
(d) weekly visits by another person with MS
Answer:
(b) regular exercise

Explanation:
An individualized regular exercise program helps the client to relieve muscle spasms. The client can be trained to use unaffected muscles to promote coordination because MS is a progressive, debilitating condition. The data do not indicate that the client needs psychotherapy, day care for the granddaughter, or visits from other clients.

Question 88.
When planning care for a client with myasthenia gravis, the nurse understands that the client is at highest risk for which health problem?
(a) aspiration
(b) bladder dysfunction
(c) hypertension
(d) sensory loss
Answer:
(a) aspiration

Explanation:
Loss of motor function to the face and throat can cause dysphagia and places the client at risk for aspiration. Bladder dysfunction and hypertension are not associated with myasthenia gravis. Myasthenia affects nerve impulses at the neuromuscular junction, causing loss of motor func-tion; there is no sensory deficit.
   
Question 89.    
The nurse is discussing discharge instructions with a client with myasthenia gravis who is taking pyridostigmine. What should the nurse instruct the client to do?
(a) Administer artificial tears.
(b) Avoid contact with crowds.
(c) Take pyridostigmine in the afternoon.
(d) Decrease protein in the diet.
Answer:
(a) Administer artificial tears.

Explanation:
The nurse instructs the client regarding use of artificial tears because eyelid and extraocular muscles are frequently affected by myasthenia gravis and there is a risk of corneal abrasion if the eyelids do not close completely. The client is encouraged to maintain social contact and prevent social isolation by staying at home. Medication is taken in the morning, prior to activities, so the client is able to complete them. A nutritious diet is encouraged, and there is no indication to limit protein.
   
Question 90.    
After teaching a client about myasthenia gravis, the nurse would judge that the client has formed a realistic concept of the disease and the treatment plan when the client makes which statement?
(a) “I’ll live longer, but ultimately the disease will cause death.”
(b) “My symptoms will be controlled, and eventually I will be cured.”
(c) “I’ll be able to control the disease and enjoy a healthy lifestyle.”
(d) “I won’t be so tired, but I can expect occasional periods of muscle weakness.”
Answer:
(c) “I’ll be able to control the disease and enjoy a healthy lifestyle.”

After teaching a client about myasthenia gravis, the nurse would judge that the client has formed a realistic concept

Explanation:
With a well-managed regimen, a client with myasthenia gravis should be able to control symptoms, maintain a normal lifestyle, and achieve a normal life expectancy. Myasthenia gravis can be controlled and need not be a fatal disease. Myasthenia gravis can be controlled, not cured. Episodes of increased muscle weakness should not occur if treatment is well managed.
   
Question 91.    
A client is brought to the emergency department unconscious. An empty bottle of aspirin was found in the car, and a drug overdose is suspected. Which medication should the nurse have available for further emergency treatment?
(a) vitamin K
(b) dextrose 50%
(c) activated charcoal powder
(d) sodium thiosulfate
Answer:
(c) activated charcoal powder

Explanation:
Activated charcoal powder is administered to absorb remaining particles of salicylate. Vitamin K is an antidote for warfarin sodium. Dextrose 50% is used to treat hypoglycemia. Sodium thiosulfate is an antidote for cyanide.
   
Question 92. 
Which clinical manifestations should the nurse expect to assess in a client diagnosed with an overdose of a cholinergic agent? Select all that apply.
(a) dry mucous membranes
(b) urinary incontinence
(c) central nervous system (CNS) depression
(d) seizures
(e) skin rash
Answer:
(b) urinary incontinence
(c) central nervous system (CNS) depression
(d) seizures

Explanation:
(b), (c), (d). An excess of cholinergic agents produces urinary and fecal incontinence, increased salivation, diarrhea, and diaphoresis. In a severe overdose, CNS depression, seizures and muscle fasciculations, bradycardia or tachycardia, weakness, and respiratory arrest due to respiratory muscle paralysis occur. Anticholinergics produce dry mucous membranes. Skin rash is not a sign of overdose with a cholinergic agent.
   
Question 93.
The nurse is caring for a client who is unconscious following an attempted suicide by drug overdose. When speaking with the client’s distraught wife, what should the nurse do first?
(a) Explain that because the client was found on hospital property, he was probably asking for help and did not intentionally overdose.
(b) Ask the wife if she would like to speak to a member of the clergy.
(c) Encourage the wife to express her feelings and concerns, and listen carefully.
(d) Allow the wife to help care for the client by rubbing his back when he is turned.
Answer:
(c) Encourage the wife to express her feelings and concerns, and listen carefully.

Explanation:
The wife’s initial response to this crisis is high anxiety. Anxiety must dissipate before a person can deal with the actual situation. Allowing the wife to express her feelings can help diffuse their anxiety. The reasons for the client’s actions are unknown; assumptions must be validated before they become facts. The nurse should first listen to the wife’s needs before recommending meeting with clergy. Asking the wife to help with the client’s care is appropriate at a later time.
   
Question 94.    
Which nursing action is a priority during the first 24 hours of hospitalization for a comatose client with suspected drug overdose?
(a) Educate regarding drug abuse.
(b) Minimize pain.
(c) Maintain intact skin.
(d) Increase caloric intake.
Answer:
(c) Maintain intact skin.

Explanation:
Maintaining intact skin is a priority for the unconscious client. Unconscious clients need to be turned every hour to prevent complications of immobility, which include pressure ulcers and stasis pneumonia. The unconscious client cannot be educated at this time. Pain is not a concern. During the first 24 hours, the unconscious client will mostly likely be on nothing-by-mouth status.
   
Question 95.    
The nurse is caring for an unconscious intubated client with normal intracranial pressure. What should the nurse include in the care plan?
(a) Monitor the oral temperature, keep the room temperature at 70°F (21.1°C), and place the client on a cooling blanket if the client’s temperature is higher than 101°F (38.3°C).
(b) Clean the mouth carefully, apply a thin coat of a water-based lubricant, and move the endotracheal tube to the opposite side daily.
(c) Position the client in the supine position with the head to the side and slightly elevated on two pillows.
(d) Turn the client with a draw-sheet, and place a pillow behind the back and one between the legs.
Answer:
(b) Clean the mouth carefully, apply a thin coat of a water-based lubricant, and move the endotracheal tube to the opposite side daily.

Explanation:
The nurse must clean the unconscious client’s mouth carefully, apply a thin coat of petroleum jelly, and move the endotracheal tube to the opposite side daily to prevent dryness, crusting, inflammation, and parotiditis. The unconscious client’s temperature should be monitored by a route other than the oral (e.g., rectal, tympanic) because oral temperatures will be inaccurate.

The client should be positioned in a lateral or semiprone position, not a supine position, to allow for drainage of secretions and for the jaw and tongue to fall forward. The client should not be dragged when turned, as may happen when a drawsheet is used. Care should be taken to lift the client’s heels, buttocks, arms, and head off of the sheets when turning. Trochanter rolls, splints, foam boot aids, specialty beds, and so on not just two pillows should be used to keep the client in correct body position and to decrease pressure on bony prominences.
   
Question 96.    
The unconscious client is to be placed in a right side-lying position. The nurse should intervene when observing a client in which position?
(a) The head is placed on a small pillow.
(b) The right leg is extended without pillow support.
(c) The left arm is rested on the mattress with the elbow flexed.
(d) The left leg is supported on a pillow with the knee flexed.
Answer:
(b) The right leg is extended without pillow support.

Explanation:
The client is not in proper body alignment if, when in the right side-lying position, the client’s left arm rests on the mattress with the elbow flexed. This positioning of the arm pulls the left shoulder out of good alignment, restricting respiratory movements. The arm should be supported on a pillow. The client’s head also should be placed on a small pillow to keep it in alignment with the body. The right leg should be extended on the mattress without a pillow to avoid hyperrotation of the hip. A pillow should be placed between the left and right legs with the left knee flexed so that on no parts of the legs is skin touching skin.
   
Question 97.    
What finding indicates that performing passive range-of-motion (ROM) exercises on an unconscious client has been successful?
(a) preservation of muscle mass
(b) prevention of bone demineralization
(c) increase in muscle tone
(d) maintenance of joint mobility
Answer:
(d) maintenance of joint mobility

Explanation:
The goal of performing passive ROM exercises is to maintain joint mobility. Active exercise is needed to preserve bone and muscle mass. Passive ROM movements do not prevent bone demineralization or have a positive effect on the client’s muscle tone.
   
Question 98.    
When the nurse performs oral hygiene for an unconscious client, which nursing intervention is the
priority?
(a) Keep a suction machine available.
(b) Place the client in a prone position.
(c) Wear sterile gloves while brushing the client’s teeth.
(d) Use gauze wrapped around the fingers to clean the client’s gums.
Answer:
(a) Keep a suction machine available.

Explanation:
Maintaining a patent airway is the priority. Therefore, the nurse should keep suction equipment available to remove secretions. The client should be placed in a side-lying, not prone, position. Performing oral hygiene is a clean procedure; therefore, the nurse wears clean gloves, not sterile gloves. The nurse should never place any fingers in an unconscious client’s mouth; the client may bite down. Padded tongue blades, swabs, or a toothbrush should be used instead; but maintaining the airway is the priority.
   
Question 99.    
The nurse observes that the right eye of an unconscious client does not close completely. Which nursing intervention is most appropriate?
(a) Have the client wear eyeglasses at all times.
(b) Lightly tape the eyelid shut.
(c) Instill artificial tears once every shift.
(d) Clean the eyelid with a washcloth every shift.
Answer:
(b) Lightly tape the eyelid shut.

Explanation:
When the blink reflex is absent or the eyes do not close completely, the cornea may become dry and irritated. Corneal abrasion can occur. Taping the eye closed will prevent injury. Having the client wear eyeglasses or cleaning the eyelid will not protect the cornea from dryness or irritation. Artificial tears instilled once per shift are not frequent enough for preventing dryness.
   
Question 100.    
Which sign is an early indicator of hypoxia in the unconscious client?
(a) cyanosis
(b) decreased respirations
(c) restlessness
(d) hypotension 
Answer:
(c) restlessness

Explanation:
Restlessness is an early indicator of hypoxia. The nurse should suspect hypoxia in the unconscious client who becomes restless. The most accurate method for determining the presence of hypoxia is to evaluate the pulse oximeter value or arterial blood gas values. Cyanosis and decreased respirations are late indicators of hypoxia. Hypertension, not hypotension, is a sign of hypoxia.
   
Question 101.
When administering intermittent enteral feeding to an unconscious client, what should the nurse do?
(a) Heat the formula in a microwave.
(b) Place the client in a semi-Fowler’s position.
(c) Obtain a sterile gavage bag and tubing.
(d) Weigh the client before administering the feeding.
Answer:
(b) Place the client in a semi-Fowler’s position.

Explanation:
The client should be placed in a semiFowler’s position to reduce the risk of aspiration. The formula should be at room temperature, not heated. Administering enteral tube feedings is a clean procedure, not a sterile one; therefore, sterile supplies are not required. Clients receiving enteral feedings should be weighed regularly, but not necessarily before each feeding.
   
Question 102.    
The unconscious client is to receive 200 mL of tube feeding every 4 hours. The nurse checks for the client’s gastric residual before administering the next scheduled feeding and obtains 40 mL of gastric residual. What should the nurse do next?
(a) Withhold the tube feeding, and notify the health care provider (HCP).
(b) Dispose of the residual, and continue with the feeding.
(c) Delay feeding the client for 1 hour, and then recheck the residual.
(d) Readminister the residual to the client, and continue with the feeding.
Answer:
(d) Readminister the residual to the client, and continue with the feeding.

Explanation:
Gastric residuals are checked before administration of enteral feedings to determine whether gastric emptying is delayed. A residual of <50% of the previous feeding volume is usually considered acceptable. In this case, the amount is not excessive and the nurse should reinstill the aspirate through the tube and then administer the feeding. If the amount of gastric residual is excessive, the nurse should notify the HCP 23 and withhold the feeding. Disposing of the residual can cause electrolyte and fluid losses.

Question 103.    
The health care provider prescribes morphine sulfate 2 to 4 mg IV push every 2 hours PRN pain for a client who has postoperative pain following abdominal surgery. Prior to performing an abdominal dressing change with packing at 1000, the nurse assesses the client’s pain level as 1 on a scale of 0 = no pain to 10 = the worst pain. The client is awake and oriented, and vital signs are within normal limits. The nurse reviews the pain medication record (see chart). What should the nurse do?

Time

Pain Level

Intervention

07:00

8

Morphine 4 mg IV

09:00

4

Morphine 2 mg IV

10:00

1

Intervention

(a) Perform the dressing change.
(b) Administer morphine 2 mg IV before the dressing change.
(c) Administer morphine 4 mg IV after the dressing change.
(d) Call the HCP for a new medication prescription.
Answer:
(b) Administer morphine 2 mg IV before the dressing change.

Explanation:
Morphine 2 mg was given 1 hour ago, and the client can have up to 4 mg every 2 hours. Although the pain level is at 1, the nurse should give medication prior to the dressing change with packing that is likely to cause discomfort. A 4-mg dose of morphine would exceed the 2-hour limit and, if given after the dressing change, would not manage pain during the procedure. The client has been responding to the pain medication dosing, and a new prescription is not required at this time.
   
Question 104.    
The nurse finds it difficult to relieve a client’s pain satisfactorily. Which measure should the nurse take next when continuing efforts to promote comfort?
(a) Increase the client’s confidence in the nurse.
(b) Enlist the help of the client’s family.
(c) Allow the client additional time to work through his or her own responses to pain.
(d) Arrange to have the client share a room with a client who has little pain.
Answer:
(a) Increase the client’s confidence in the nurse.

Explanation:
Experience has demonstrated that clients who feel confidence in the persons who are caring for them do not require as much therapy for pain relief as do those who have less confidence. Without the client’s confidence, developed in an effective nurse-client relationship, other interventions may be less effective. The client’s family can be an important source of support, but it is the nurse who plans strategies for pain relief. The client may require time to adjust to the pain, but the nurse and client can collaborate to try to evaluate a variety of pain relief strategies. Arranging for the client to share a room with another client who has little pain may have negative effects on the client who has pain that is difficult to relieve.
   
Question 105.
A client is arousing from a coma and keeps saying, “just stop the pain.” The nurse responds based on the knowledge that the client’s first response to pain will be to do what?
(a) Tolerate the pain.
(b) Decrease the perception of pain.
(c) Escape the source of pain.
(d) Divert attention from the source of pain.
Answer:
(c) Escape the source of pain.

Explanation:
The client’s innate responses to pain are directed initially toward escaping from the source of pain. Variations in tolerance and perception of pain are apparent only in conscious clients, and only conscious clients can employ distraction to help relieve pain.
   
Question 106.    
Ergotamine tartrate is prescribed for a client’s migraine headaches. What is the expected outcome of the use of this drug?
(a) prevention of the migraine
(b) aborting of the developing migraine 
(c) relief from the sleeplessness experienced in the past after a migraine
(d) relief from the vision problems experienced in the past after a migraine
Answer:
(b) aborting of the developing migraine 

Explanation:
Ergotamine tartrate is used to help abort a migraine attack. It should be taken as soon as prodromal symptoms appear. Reduced migraine severity and relief from sleeplessness and vision problems address symptoms that occur after the migraine has occurred and are not effects of ergotamine.

Question 107.    
A client is using biofeedback to manage pain. The nurse can explain to the client that biofeedback will enable the client to exert control over physiologic processes by which mechanism?
(a) regulating the body's processes through electrical control
(b) shocking the client when an undesirable response is elicited
(c) monitoring the body processes for the therapist to interpret
(d) translating the signals of body processes into observable forms
Answer:
(d) translating the signals of body processes into observable forms

A client is using biofeedback to manage pain. the nurse can explain to the client that biofeedback will enable the client

Explanation:
Biofeedback translates body processes into observable signs so that the client can develop some control over certain body processes. Biofeedback does not involve electrical stimulation. The use of unpleasant stimuli such as electrical shock is a form of aversion therapy. Biofeedback does not involve monitoring body processes for the therapist to interpret; rather, it is a self-directed, self-care activity that reinforces learning because the client can see the results of his or her actions.
   
Question 108.
A client is receiving massage therapy to relieve pain. Which statement explains why massage is an effective way to relieve pain?
Massage therapy:
(a) blocks pain impulses from the spinal cord to the brain.
(b) blocks pain impulses from the brain to the spinal cord.
(c) stimulates the release of endorphins.
(d) distracts the client’s focus on the source of the pain.
Answer:
(a) blocks pain impulses from the spinal cord to the brain.

Explanation:
A back rub stimulates the large-diameter cutaneous fibers, which block the transmission of pain impulses from the spinal cord to the brain. It does not block the transmission of pain impulses or stimulate the release of endorphins. A back rub may distract the client, but the physiologic process of fiber stimulation is the main reason a back rub is used as therapy for pain relief.
   
Question 109. 
A client is using patient-controlled analgesia (PCA) to manage postoperative pain. What should the nurse do when assisting the client with the PCA?
(a) Reassure the client that pain will be relieved.
(b) Document the client’s response to pain medication.
(c) Instruct the client to continue pressing the system’s button whenever pain occurs.
(d) Titrate pain medication until the client is free from pain.
Answer:
(b) Document the client’s response to pain medication.

Explanation:
It is essential that the nurse document the client’s response to pain medication on a routine, systematic basis. Reassuring the client that pain will be relieved is often not realistic. A client who continually presses the PCA button may not be getting adequate pain relief, but through careful assessment and documentation, the effectiveness of pain relief interventions can be evaluated and modified. Pain medication is not titrated until the client is free from pain but rather until an acceptable level of pain management is reached.
   
Question 110. 
A client has a patient-controlled analgesia (PCA) infusion to manage postoperative pain. In spite of receiving a dose of pain medication, the client rates the pain at 8 on a 0 to 10 pain scale. What should the nurse do first?
(a) Check the patient-controlled analgesia (PCA) pump function.
(b) Inspect the infusion site.
(c) Assess vital signs.
(d) Notify the health care provider (HCP).
Answer:
(b) Inspect the infusion site.

Explanation:
The nurse should first check the infusion site to be sure the site has not infiltrated. Next, the nurse should check the PCA pump to determine if it is functioning properly. Assessing vital signs would be important to provide additional data about the possible cause of pain, but is not the first action at this time. It is not necessary to notify the health care provider (HCP) |jj unless the infusion site or pump is malfunctioning and other methods of managing the pain are required.
   
Question 111.
A client is using healing touch therapy to manage pain. What should the nurse tell the client about how healing touch can be effective in pain management?
Healing touch involves:
(a) directing the flow of energy fields.
(b) lightly touching the client skin.
(c) massaging the client’s muscles.
(d) increasing endorphin production.
Answer:
(a) directing the flow of energy fields.

Explanation:
The nurse using healing touch affects a client’s pain primarily through assessing and directing the flow of energy fields. Healing touch removes energy congestion so energy channels can facilitate integration of the body, mind, and soul to promote healing. Healing touch can involve touching, but it does not have to involve body contact. Massage is not involved with healing touch. The goal of healing touch is not to increase the production of endorphins.
   
Question 112.
When a nurse is assessing a client for pain, what finding is most significant? The client:
(a) protects a specific area of the body.
(b) tells the nurse about experiencing pain.
(c) has a change in vital signs.
(d) appears to be uncomfortable.
Answer:
(b) tells the nurse about experiencing pain.

Explanation:
Pain is whatever the client perceives it is; using a pain scale is the best way to have the client quantify the amount of pain. The fact that the client is protecting an area of the body, the client’s vital signs, and the client’s appearance of discomfort are objective rather than subjective findings; the nurse should confirm the meaning of these changes before assuming the client has pain.
   
Question 113.    
A client who is 89 years of age is in traction for a broken hip. At 1100 on 3/26, the client is experiencing pain. Prescriptions include morphine sulfate 2 to 4 mg intravenous push every 2 to 4 hours for pain. The client rates the pain as an 8 on the visual analog scale (0 to 10). Prior to intervening to manage the pain, the nurse reviews the progress notes (see exhibit).

Date

Time

Progress Notes

3/26

09:00

Client is alert and oriented. Vital sings: pulse 80, respirations 14, BP 100/80, and oxygen saturation by pulse oximater 9.2%. Received morphine Sulfate 2 mg by intravenous push (IVP).

3/26

10:00

Claint has Pain of 4 on the visual
Analog Scale (0-10).
Respirations are 10.

At 1100 on 3/26, what should the nurse do?
(a) Reposition the client for comfort, and administer pain medication in another 2 hours.
(b) Administer 2 mg morphine sulfate IVP now, and reassess in 10 to 15 minutes.
(c) Call the health care provider (HCP) for supplemental medication to relax the client and promote sedation.
(d) Administer 2 mg morphine sulfate IVP in 2 hours if the respirations are above 12 breaths/min.
Answer:
(b) Administer 2 mg morphine sulfate IVP now, and reassess in 10 to 15 minutes.

Explanation:
The nurse administers between 2 and 4 mg of morphine sulfate IVP every 2 to 4 hours according to the prescription for pain management. Even though the client received pain medication 2 hours ago, the client is still experiencing pain of the intensity of 8 on a scale of 0 to 10. Elderly clients may have slowed pain perception but not diminished pain intensity. The nurse starts out conservatively, administering 2 mg of morphine sulfate IVP and reassessing in 15 minutes to determine the effectiveness of pain management and respiratory effort. If pain is still not relieved, the titration of morphine sulfate upward to 4 mg is optional.

The single provision of nonpharmaco-logic interventions such as repositioning is not sufficient pain management when a client rates pain at 8 on a scale of 0 to 10. Requesting a prescription for sedation only causes the client to be unable to express her pain and does not treat the pain. Although the nurse continues to monitor the client’s respirations, the respirations are not dangerously depressed, and waiting another 2 hours to administer pain medication does not address the client’s need for pain relief.

Question 114.    
When caring for a client with Guillain-Barre syndrome, the nurse can delegate which activity to the unlicensed assistive personnel (UAP)?
(a) Assess weakness with range-of-motion exercises.
(b) Reposition client every 2 hours.
(c) Suction the endotracheal tube.
(d) Show the client how to do deep-breathing exercises.
Answer:
(b) Reposition client every 2 hours.

Explanation:
Assessments, teaching, and suctioning are roles of the nurse. Basic care with frequent positioning is the most appropriate to delegate to the UAP. 
   
Question 115.    
An unlicensed assistive personnel (UAP) is providing care to a client with left-sided paralysis. Which action by the UAP requires the nurse to provide further instruction?
(a) providing passive range-of-motion exercises to the left extremities during the bed bath
(b) elevating the foot of the bed to reduce edema
(c) pulling up the client under the left shoulder when getting the client out of bed to a chair
(d) putting high top tennis shoes on the client after bathing
Answer:
(c) pulling up the client under the left shoulder when getting the client out of bed to a chair

Explanation:
Pulling the client up under the arm can cause shoulder displacement. A belt around the waist should be used to move the client. Passive range-of-motion exercises prevent contractures and atrophy. Raising the foot of the bed assists in venous return to reduce edema. High top tennis shoes are used to prevent foot drop.
   
Question 116.
The nurse notices that a client with Parkinson’s disease is coughing frequently when eating. Which intervention should the nurse consider?
(a) Have the client hyperextend the neck when swallowing.
(b) Tell the client to place the chin firmly against the chest when eating.
(c) Thicken all liquids before offering to the client.
(d) Place the client on a clear liquid diet. 
Answer:
(c) Thicken all liquids before offering to the client.

Explanation:
Clients with Parkinson’s disease can experience dysphagia. Thickening liquids assists with swallowing, preventing aspiration. Hyperextending the neck opens the airway and can increase risk of aspiration. Pressing the chin firmly on the chest makes swallowing more difficult. The chin should be slightly tucked to promote swallowing. The nurse should suggest a speech therapy consult for evaluation of the client’s ability to swallow.
   
Question 117.    
After receiving a change-of-shift report at 0700, the nurse should assess which client first?
(a) a 23-year-old with a migraine headache who has severe nausea associated with retching
(b) a 45-year-old who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching
(c) a 59-year-old with Parkinson’s disease who will need a swallowing assessment before breakfast
(d) a 63-year-old with multiple sclerosis who has an oral temperature of 101.8°F (38.8°C) and flank pain 
Answer:
(d) a 63-year-old with multiple sclerosis who has an oral temperature of 101.8°F (38.8°C) and flank pain 

Explanation:
 Urinary tract infections are a frequent complication in clients with multiple sclerosis because of the effect on bladder function; therefore, that client should been seen first by the nurse. The elevated temperature and flank pain suggest that this client may have pyelonephritis. The client should be notified immediately so that antibiotic therapy can be started quickly. The other clients should be assessed soon but do not have needs as urgent as this client.  
  
Question 118.    
The nurse has asked the unlicensed assistive personnel (UAP) to ambulate a client with Parkinson’s disease. The nurse observes the UAP pulling on the client’s arms to get the client to walk forward. What should the nurse do?
(a) Have the UAP keep a steady pull on the client to promote forward ambulation.
(b) Explain how to overcome a freezing gait by telling the client to march in place.
(c) Assist the UAP with getting the client back in bed.
(d) Give the client a muscle relaxant.
Answer:
(b) Explain how to overcome a freezing gait by telling the client to march in place.

Explanation:
Clients with Parkinson’s disease may experience a freezing gait when they are unable to move forward. Instructing the client to march in place, step over lines in the flooring, or visualize stepping over a log allows them to move forward. It is important to ambulate the client and not keep him or her on bed rest. A muscle relaxant is not indicated.
   
Question 119.    
Which pressure point areas should the nurse monitor for an unconscious client positioned on the right side (see figure)? Select all that apply.
Neurologic Health Problems NCLEX Questions with Rationale 1 
(a) ankles
(b) ear
(c) greater trochanter
(d) heels
(e) shoulder
Answer:
(a) ankles
(b) ear
(c) greater trochanter
(e) shoulder

Explanation:
(a), (b), (c), (e). Pressure points in the side-lying position include the ears, shoulders, ribs, greater trochanter, medial or lateral condyles, and ankles. The sacrum, occiput, and heels are pressure point areas affected in the supine position.
   
Question 120.    
The nurse ascertains that there is a discrepancy in the records of use of a controlled substance for a client who is taking large doses of narcotic pain medication. What should the nurse do next?
(a) Notify the police.
(b) Contact the hospital’s administration or legal department.
(c) Notify the pharmacy technician who delivered the controlled substance.
(d) Notify the nursing supervisor of the clinical unit.
Answer:
(d) Notify the nursing supervisor of the clinical unit.

Explanation:
All healthcare facilities in which controlled medications are stored for dispensing and/ or administration to clients are required to follow procedures for the proper maintenance of narcotic inventory. Narcotic inventory maintenance includes but is not limited to, thorough and appropriate documentation of any discrepancy with accompanying reasons (i.e., tablet/amp/vial breakage, additional medication volume), timely resolution of inventory discrepancies, and timely notification of persons in oversight areas (i.e., pharmacy, security, nursing house supervisor). In the event of a significant incident, the proper external authorities will be notified by the Quality and Risk Management/Legal Department.
   
Question 121. 
The nurse is caring for a client who is confused about time and place. The client has intravenous fluid infusing. The nurse attempts to reorient the client, but the client remains unable to demonstrate appropriate use of the call light. In order to maintain client safety, what should the nurse do first?
(a) Ask the family to stay with the client.
(b) Contact the health care provider, and request a prescription for soft wrist restraints.
(c) Increase the frequency of client observation.
(d) Administer a sedative.
Answer:
(c) Increase the frequency of client observation.

The nurse is caring for a client who continues to be confused about time and place

Explanation:
The first intervention for a confused client is to increase the frequency of observation, moving the client closer to the nurses’ station if possible and/or delegating the unlicensed assistive personnel (UAP) to check on the client more frequently. If the family is able to stay with the client, that is an option, but it is the nurse’s responsibility, not the family’s, to keep the client safe. Wrist restraints are not used simply because a client is confused; there is no mention of this client pulling at intravenous lines, which is one of the main reasons to use wrist restraints. Administering a sedative simply because a client is confused is not appropriate nursing care and may actually potentiate the problem.
   
Question 122. 
The nurse finds a confused client with soft wrist restraints in place (see figure). What should the nurse do first?
Neurologic Health Problems NCLEX Questions with Rationale 2
(a) Assess and document the condition of the client’s skin beneath the restraint.
(b) Untie the restraint and resecure to the bed frame using a quick-release knot.
(c) Release the restraint and perform passive range of motion.
(d) Ask if the client needs to use the restroom.
Answer:
(b) Untie the restraint and resecure to the bed frame using a quick-release knot.

Explanation:   
To ensure the client’s safety when using restraints, the restraint must be secured to the bed frame (not the side rail) using a quick-release slip knot (not a square knot). Assessing and documenting skin should be done regularly when restraints are in use, but safety is first priority. Regularly releasing restraints and performing range of motion is essential but not priority in this case. Providing for the client’s basic needs while in restraints (i.e., toileting) is important but not first priority.

Book an appointment