MEDSURG NEUROLOGICAL DISORDERS NCLEX
QUESTIONS WITH APPROVED ANSWERS |2026 UPLOAD
|ALREADY GRADED A+
Regular oral hygiene is an essential intervention for a client who has had a stroke.
Which of the following nursing measures is inappropriate when providing oral
hygiene?
A. Placing the client on the back with a small pillow under the head.
B. Keeping portable suctioning equipment at the bedside.
C. Opening the client's mouth with a padded tongue blade.
D. Cleaning the client's mouth and teeth with a toothbrush. - ANS -A.
client should be positioned on the side, not on the back. This lateral position helps
secretions escape from the throat and mouth, minimizing the risk of aspiration.
A 78-year-old client is admitted to the emergency department with numbness
and weakness of the left arm and slurred speech. Which nursing intervention is a
priority?
A. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
B. Discuss the precipitating factors that caused the symptoms.
C. Schedule for A STAT computer tomography (CT) scan of the head.
D. Notify the speech pathologist for an emergency consultation. - ANS -C.
A CT scan will determine if the client is having a stroke or has a brain tumour or
another neurological disorder. This would also determine if it is a hemorrhagic or
,ischemic accident and guide the treatment because only an ischemic stroke can
use tPA.
A client arrives in the emergency department with an ischemic stroke and
receives tissue plasminogen activator (t-PA) administration. Which is the priority
nursing assessment?
A. Time of onset of current stroke
B. Complete physical and history
C. Current medications
D. Upcoming surgical procedures - ANS -A.
The time of onset of a stroke to t-PA administration is critical. Administration
within 3 hours has better outcomes. Tissue plasminogen activator (tPA) is
classified as a serine protease (enzymes that cleave peptide bonds in proteins). It
is thus one of the essential components of the dissolution of blood clots. Its
primary function includes catalyzing the conversion of plasminogen to plasmin,
the primary enzyme involved in dissolving blood clots.
During the first 24 hours after thrombolytic therapy for ischemic stroke, the
primary goal is to control the client's:
A. Pulse
B. Respirations
C. Blood pressure
D. Temperature - ANS -C.
Controlling the blood pressure is critical because an intracerebral hemorrhage is
the major adverse effect of thrombolytic therapy. Blood pressure should be
,maintained according to the physician and is specific to the client's ischemic tissue
needs and risks of bleeding from treatment.
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 - ANS -B.
It is crucial to monitor the pupil size and pupillary response to indicate changes
around the cranial nerves. Pupil reactions are regulated by the oculomotor (III)
cranial nerve and are useful in determining whether the brain stem is intact. Pupil
size and equality is determined by a balance between parasympathetic and
sympathetic innervation. Response to light reflects the combined function of the
optic (II) and oculomotor (III) cranial nerves.
What is the expected outcome of thrombolytic drug therapy?
A. Increased vascular permeability
B. Vasoconstriction
C. Dissolved emboli
D. Prevention of hemorrhage - ANS -C.
Thrombolytic therapy is used to dissolve emboli and reestablish cerebral
perfusion. Thrombolytic treatment is also known as fibrinolytic or thrombolysis,
to dissolve dangerous intravascular clots to prevent ischemic damage by
improving blood flow. Thrombosis is a significant physiological response that
limits hemorrhage caused by large or tiny vascular injury.
, The client diagnosed with atrial fibrillation has experienced a transient ischemic
attack (TIA). Which medication would the nurse anticipate being ordered for the
client on discharge?
A. A thrombolytic medication
B. A beta-blocker medication
C. An anti-hyperuricemic medication
D. An oral anticoagulant medication - ANS -D.
Thrombi form secondary to atrial fibrillation. Therefore, an anticoagulant would
be anticipated to prevent thrombus formation; and oral (warfarin [Coumadin]) at
discharge versus intravenous. Oral anticoagulation is indicated for patients with
atrial fibrillation or other sources of cardioembolic sources of TIA.
Which client would the nurse identify as being most at risk for experiencing a
CVA?
A. A 39-year-old pregnant female.
B. A 67-year-old Caucasian male.
C. An 84-year-old Japanese female.
D. A 55-year-old African American male. - ANS -D.
African Americans have twice the rate of CVAs as Caucasians; males are more
likely to have strokes than females except in advanced years. Of all the risk
factors, hypertension is the most common modifiable risk factor for stroke.
Hypertension is most prevalent in African-Americans and also occurs earlier in
life.
QUESTIONS WITH APPROVED ANSWERS |2026 UPLOAD
|ALREADY GRADED A+
Regular oral hygiene is an essential intervention for a client who has had a stroke.
Which of the following nursing measures is inappropriate when providing oral
hygiene?
A. Placing the client on the back with a small pillow under the head.
B. Keeping portable suctioning equipment at the bedside.
C. Opening the client's mouth with a padded tongue blade.
D. Cleaning the client's mouth and teeth with a toothbrush. - ANS -A.
client should be positioned on the side, not on the back. This lateral position helps
secretions escape from the throat and mouth, minimizing the risk of aspiration.
A 78-year-old client is admitted to the emergency department with numbness
and weakness of the left arm and slurred speech. Which nursing intervention is a
priority?
A. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
B. Discuss the precipitating factors that caused the symptoms.
C. Schedule for A STAT computer tomography (CT) scan of the head.
D. Notify the speech pathologist for an emergency consultation. - ANS -C.
A CT scan will determine if the client is having a stroke or has a brain tumour or
another neurological disorder. This would also determine if it is a hemorrhagic or
,ischemic accident and guide the treatment because only an ischemic stroke can
use tPA.
A client arrives in the emergency department with an ischemic stroke and
receives tissue plasminogen activator (t-PA) administration. Which is the priority
nursing assessment?
A. Time of onset of current stroke
B. Complete physical and history
C. Current medications
D. Upcoming surgical procedures - ANS -A.
The time of onset of a stroke to t-PA administration is critical. Administration
within 3 hours has better outcomes. Tissue plasminogen activator (tPA) is
classified as a serine protease (enzymes that cleave peptide bonds in proteins). It
is thus one of the essential components of the dissolution of blood clots. Its
primary function includes catalyzing the conversion of plasminogen to plasmin,
the primary enzyme involved in dissolving blood clots.
During the first 24 hours after thrombolytic therapy for ischemic stroke, the
primary goal is to control the client's:
A. Pulse
B. Respirations
C. Blood pressure
D. Temperature - ANS -C.
Controlling the blood pressure is critical because an intracerebral hemorrhage is
the major adverse effect of thrombolytic therapy. Blood pressure should be
,maintained according to the physician and is specific to the client's ischemic tissue
needs and risks of bleeding from treatment.
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 - ANS -B.
It is crucial to monitor the pupil size and pupillary response to indicate changes
around the cranial nerves. Pupil reactions are regulated by the oculomotor (III)
cranial nerve and are useful in determining whether the brain stem is intact. Pupil
size and equality is determined by a balance between parasympathetic and
sympathetic innervation. Response to light reflects the combined function of the
optic (II) and oculomotor (III) cranial nerves.
What is the expected outcome of thrombolytic drug therapy?
A. Increased vascular permeability
B. Vasoconstriction
C. Dissolved emboli
D. Prevention of hemorrhage - ANS -C.
Thrombolytic therapy is used to dissolve emboli and reestablish cerebral
perfusion. Thrombolytic treatment is also known as fibrinolytic or thrombolysis,
to dissolve dangerous intravascular clots to prevent ischemic damage by
improving blood flow. Thrombosis is a significant physiological response that
limits hemorrhage caused by large or tiny vascular injury.
, The client diagnosed with atrial fibrillation has experienced a transient ischemic
attack (TIA). Which medication would the nurse anticipate being ordered for the
client on discharge?
A. A thrombolytic medication
B. A beta-blocker medication
C. An anti-hyperuricemic medication
D. An oral anticoagulant medication - ANS -D.
Thrombi form secondary to atrial fibrillation. Therefore, an anticoagulant would
be anticipated to prevent thrombus formation; and oral (warfarin [Coumadin]) at
discharge versus intravenous. Oral anticoagulation is indicated for patients with
atrial fibrillation or other sources of cardioembolic sources of TIA.
Which client would the nurse identify as being most at risk for experiencing a
CVA?
A. A 39-year-old pregnant female.
B. A 67-year-old Caucasian male.
C. An 84-year-old Japanese female.
D. A 55-year-old African American male. - ANS -D.
African Americans have twice the rate of CVAs as Caucasians; males are more
likely to have strokes than females except in advanced years. Of all the risk
factors, hypertension is the most common modifiable risk factor for stroke.
Hypertension is most prevalent in African-Americans and also occurs earlier in
life.
