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NCLEX MED SURG STROKE AND ANSWERS 2025 VERSION VERIFIED RATIONALE GRADED A+.pdf

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NCLEX MED SURG STROKE AND ANSWERS 2025 VERSION VERIFIED RATIONALE GRADED A+.pdf

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Hochgeladen auf
17. juli 2025
Anzahl der Seiten
10
geschrieben in
2024/2025
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Prüfung
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NCLEX MED SURG STROKE AND ANSWERS 2024
VERSION VERIFIED RATIONALE GRADED A+


Which of the following is the best treatment for acute ischemic stroke?

Which of the following is the best treatment for acute ischemic stroke?

Which intervention should the nurse delegate to the LPN when caring for a patient following an acute
stroke?

Treat for hemorrhagic stroke - ansLower BP

To promote communication during rehabilitation of the patient with aphasia, an appropriate nursing
intervention is to

The priority intervention in the emergency department for the patient with a stroke is

The nurse can assist the patient and the family in coping with the long term effects of a stroke by

The neurologic functions that are affected by a stroke are primarily related to

The incidence of ischemic stroke in patients with TIAs and other risk factors is reduced with
administration of

The communication between cerebral arteries in the circle of Willing provides a collateral circulation,
which may maintain circulation to an area of the brain if its original blood supply is obstructed. ALl areas
of the brain require constant blood supply, and atherosclerotic plaques are not readily reversed.
Neurologic deficits can result from ischemia cause by many factors.

Secondary prevention: Risk factor modification (4) - ans1. smoking cessation

Secondary prevention of stroke (3) - ans1. Anticoagulants

Problem with IV-TPA - ansonly 1-3% of patients arrive in time to receive it

Permissive hypertension - ansIf you drop blood pressure then more green tissue (ischemic) turns red
(infarcted)

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Most common artery involved - ansInternal Carotid Artery

Manifestations of right brain damage - ansLeft homonymous hemianopsia, agnosia, quick impulsive
behavior, neglect of the left side of the body

Manifestations of left brain damage - ansAphasia, inability to remember words

In promoting health maintenance for prevention of strokes, the nurse understands that the highest risk
for the most common type of stroke is present in

Four days following a stroke, a patient is to start oral fluids and feedings. Before feeding the patient, the
nurse should first

, NCLEX MED SURG STROKE AND ANSWERS 2024
VERSION VERIFIED RATIONALE GRADED A+


e. Warfarin - ansC: Alteplase

e. Warfarin

During the acute phase of a stroke, the nurse assesses the patient's vital signs and neurologic status
every 4 hours. A cardiovascular sign that the nurse would see as the body attempts to increase cerebral
blood flow is

d. use flashcards with simple words and pictures to promote language recall - ansB: Talk about ADLs that
are familiar to the patient- during rehabilitation, the patient with aphasia needs frequent, meaningful
verbal stimulation that has relevance for him. Conversation by the nurse and family should address ADLs
that are familiar to the patient. Gestures, pictures, and simple statements are more appropriate in the
acute phase, when patients may be overwhelmed with verbal stimuli. Flashcards are often perceived by
the patient as childish and meaningless.

d. those who are obese with high dietary fat intake - ansC: Individuals with hypertension and diabetes-
The highest risk factors for thrombotic stroke are hypertension and diabetes. African Americans have a
higher risk for stroke than do white persons but probably because they have a greater incidence of
hypertension. Factors such as obesity, diet high in saturated fats and cholesterol, cigarette smoking, and
excessive alcohol use are also risk factors but carry less risk than hypertension.

d. the presence or absence of collateral circulation - ansC: The brain area perfused by the affected
artery- clinical manifestation of altered neurologic function differ, depending primarily on the specific
cerebral artery involved and the area of the brain that is perfused by the artery. The degree of
impairment depends on rapidity of onset, the size of the lesion, and the presence of collateral
circulation.

d. the patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive
cerebral vascular disease - ansD: The patient has probably experienced a transient ischemic attack (TIA),
which is a sign of progressive cerebral vascular disease- A TIA is a temporary focal loss of neurologic
function caused by ischemia of an area of the brain, usually lasting only about 3 hours. TIAs may be due
to microemboli from heart disease or carotid or cerebral thrombi and are a warning of progressive
disease. Evaluation is necessary to determine the cause of the neurologic deficit and provide
prophylactic treatment if possible.

d. The medication you are talking about dissolves clots and could cause more bleeding in your husband's
head - ansD: The medication you are talking about dissolves clots and could cause more bleeding in your
husband's head- tPA dissolves clots and increases the risk for bleeding. It is not used with hemorrhagic
strokes. If the patient had a thrombotic/embolic stroke the time frame would be important as well as a
history of surgery. The nurse should answer the question as accurately as possible and then encourage
the individual to talk with the primary care physician if he or she has further questions.
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