ECHELON STROKE FULL STUDY SHEET
QUESTIONS AND CORRECT ANSWERS
COLLECTION
●● An emergency department nurse is interviewing a client with signs of
an ischemic stroke that began 2 hours ago. The client reports that she
had a cholecystectomy 6 weeks ago and is taking digoxin, coumadin,
and labetelol. This client is not eligible for thrombolytic therapy for
which of the following reasons?
a) She is not within the treatment time window.
b) She had surgery 6 weeks ago.
c) She is taking digoxin.
d) She is taking coumadin.
Answer: She is taking coumadin.
To be eligible for thrombolytic therapy, the client cannot be taking
coumadin. Initiation of thrombolytic therapy must be within 3 hours in
clients with ischemic stroke. The client is not eligible for thrombolytic
,therapy if she has had surgery within 14 days. Digoxin and labetelol do
not prohibit thrombolytic therapy.
●● Which disturbance results in loss of half of the visual field?
a) Anisocoria
b) Homonymous hemianopsia
c) Nystagmus
d) Diplopia
Answer: Homonymous hemianopsia
Homonymous hemianopsia (loss of half of the visual field) may occur
from stroke and may be temporary or permanent. Double vision is
documented as diplopia. Nystagmus is ocular bobbing and may be seen
in multiple sclerosis. Anisocoria is unequal pupils.
●● A client with a cerebrovascular accident (CVA) is having difficulty
with eating food on the plate. Which is the best nursing action to be
taken?
,a) Reposition the tray and plate.
b) Perform a vision field assessment.
c) Know this is a normal finding for CVA.
d) Assist the client with feeding.
Answer: Perform a vision field assessment.
The nurse should perform a vision field assessment to evaluate the client
forhemianopia. This finding could indicate damage to the visual area of
the brain as a result of evolving CVA. Repositioning the tray and
assisting with feeding would not be the best nursing action until new
finding has been evaluated. Hemianopia can be associated with a CVA
but, when presenting as a new finding, should be evaluated and reported
immediately. (less)
●● A client is hospitalized when they present to the Emergency
Department with right-sided weakness. Within 6 hours of being
admitted, the neurologic deficits had resolved and the client was back to
their presymptomatic state. The nurse caring for the client knows that
the probable cause of the neurologic deficit was what?
, a) Cerebral aneurysm
b) Transient ischemic attack
c) Left-sided stroke
d) Right-sided stroke
Answer: Transient ischemic attack
A transient ischemic attack (TIA) is a sudden, brief attack of neurologic
impairment caused by a temporary interruption in cerebral blood flow.
Symptoms may disappear within 1 hour; some continue for as long as 1
day. When the symptoms terminate, the client resumes his or her
presymptomatic state. The symptoms do not describe a left- or right-
sided stroke or a cerebral aneurysm.
●● Which of the following terms refer to the failure to recognize
familiar objects perceived by the senses?
a) Agnosia
b) Perseveration
QUESTIONS AND CORRECT ANSWERS
COLLECTION
●● An emergency department nurse is interviewing a client with signs of
an ischemic stroke that began 2 hours ago. The client reports that she
had a cholecystectomy 6 weeks ago and is taking digoxin, coumadin,
and labetelol. This client is not eligible for thrombolytic therapy for
which of the following reasons?
a) She is not within the treatment time window.
b) She had surgery 6 weeks ago.
c) She is taking digoxin.
d) She is taking coumadin.
Answer: She is taking coumadin.
To be eligible for thrombolytic therapy, the client cannot be taking
coumadin. Initiation of thrombolytic therapy must be within 3 hours in
clients with ischemic stroke. The client is not eligible for thrombolytic
,therapy if she has had surgery within 14 days. Digoxin and labetelol do
not prohibit thrombolytic therapy.
●● Which disturbance results in loss of half of the visual field?
a) Anisocoria
b) Homonymous hemianopsia
c) Nystagmus
d) Diplopia
Answer: Homonymous hemianopsia
Homonymous hemianopsia (loss of half of the visual field) may occur
from stroke and may be temporary or permanent. Double vision is
documented as diplopia. Nystagmus is ocular bobbing and may be seen
in multiple sclerosis. Anisocoria is unequal pupils.
●● A client with a cerebrovascular accident (CVA) is having difficulty
with eating food on the plate. Which is the best nursing action to be
taken?
,a) Reposition the tray and plate.
b) Perform a vision field assessment.
c) Know this is a normal finding for CVA.
d) Assist the client with feeding.
Answer: Perform a vision field assessment.
The nurse should perform a vision field assessment to evaluate the client
forhemianopia. This finding could indicate damage to the visual area of
the brain as a result of evolving CVA. Repositioning the tray and
assisting with feeding would not be the best nursing action until new
finding has been evaluated. Hemianopia can be associated with a CVA
but, when presenting as a new finding, should be evaluated and reported
immediately. (less)
●● A client is hospitalized when they present to the Emergency
Department with right-sided weakness. Within 6 hours of being
admitted, the neurologic deficits had resolved and the client was back to
their presymptomatic state. The nurse caring for the client knows that
the probable cause of the neurologic deficit was what?
, a) Cerebral aneurysm
b) Transient ischemic attack
c) Left-sided stroke
d) Right-sided stroke
Answer: Transient ischemic attack
A transient ischemic attack (TIA) is a sudden, brief attack of neurologic
impairment caused by a temporary interruption in cerebral blood flow.
Symptoms may disappear within 1 hour; some continue for as long as 1
day. When the symptoms terminate, the client resumes his or her
presymptomatic state. The symptoms do not describe a left- or right-
sided stroke or a cerebral aneurysm.
●● Which of the following terms refer to the failure to recognize
familiar objects perceived by the senses?
a) Agnosia
b) Perseveration
