NCLEX MED SURG STROKE AND ANSWERS 2024
VERSION VERIFIED RATIONALE GRADED A+
A patient is admitted to the hospital with a left hemiplegia. To determine the size and location and to ascertain whether a stroke is
ischemic or hemorrhagic, the nurse anticipates that the health care provider will request a
a. CT scan
b. lumbar puncture
c. cerebral arteriogram
d. positron emission tomography (PET) - ansA: CT scan- A CT scan is the most commonly used diagnostic test to determine the
size and location of the lesion and to differentiate a thrombotic stroke from a hemorrhagic stroke. Positron emission tomography
(PET) will show the metabolic activity of the brain and provide a depiction of the extent of tissue damage after a stroke. Lumbar
punctures are not performed routinely because of the chance of increased intracranial pressure causing herniation. Cerebral
arteriograms are invasive and may dislodge an embolism or cause further hemorrhage; they are performed only when no other test
can provide the needed information.
A patient with a stroke has a right sided hemiplegia. The nurse prepares family members to help control behavior changes seen with
this type of stroke by teaching them to
a. ignore undesirable behaviors manifested by the patient
b. provide directions to the patient verbally in small steps
c. distract the patient from inappropriate emotional responses
d. supervise all activities before allowing the patient to pursue them independently - ansC: Distract the patient from inappropriate
emotional responses- patients with left-sided brain damage from stroke often experience emotional lability, inappropriate emotional
responses, mood swings, and uncontrolled tears or laughter disproportionate or out of context with the situation. The behavior is
upsetting and embarrassing to both the patient and the family, and the patient should be distracted to minimize its presence.
Patients with right-brain damage often have impulsive, rapid behavior that supervision and direction.
A patient with right hemisphere stroke has a nursing diagnosis of unilateral neglect related to sensory perceptual deficits. During the
patient's rehabilitation, it is important for the nurse to
a. avoid positioning the patient on the affected side
b. place all objects for care on the patient's unaffected side
c. teach the patient to care consciously for the affected side
d. protect the affected side from injury with pillows and supports - ansC: Teach the patient to care consciously for the affected side-
unilateral neglect, or neglect syndrome, occurs when the patient with a stroke is unaware of the affected side of the body, which puts
the patient at risk for injury. During the acute phase, the affected side is cared for by the nurse with positioning and support, during
rehabilitation the patient is taught to care consciously for and attend to the affected side of the body to protect it from injury. Patients
may be positioned on the affected side for up to 30 minutes.
A patient's wife asks the nurse why her husband did not receive the clot busting medication (tPA) she has been reading about. Her
husband is diagnosed with a hemorrhagic stroke. What should the nurse respond?
a. He didn't arrive within the time frame for that therapy
b. Not every is eligible for this drug. Has he had surgery lately?
c. You should discuss the treatment of your husband with your doctor
, NCLEX MED SURG STROKE AND ANSWERS 2024
VERSION VERIFIED RATIONALE GRADED A+
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.
A thrombus that develops in a cerebral artery does not always cause a loss of neurologic function because
a. the body can dissolve the atherosclerotic plaques as they form
b. some tissues of the brain do not require constant blood supply to prevent damage
c. circulation through the circle of Willis may provide blood supply to the affected area of the brain
d. neurologic deficits occur only when major arteries are occluded by thrombus formation around an atherosclerotic plaque - ansC:
Circulation through the circle of Willis may provide blood supply to the affected area of the brain.
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.
An appropriate food for a patient with a stroke who has mild dysphagia is
a. fruit juices
b. pureed meat
c. scrambled eggs
d. fortified milkshakes - ansC: scrambled eggs- soft foods that provide enough texture, flavor, and bulk to stimulate swallowing
should be used for the patient with dysphasia. Thin liquids are difficult to swallow, and patients may not be able to control them in
the mouth. Pureed foods are often too bland and to smooth, and milk products should be avoided because they tend to increase the
viscosity of mucus and increase salivation.
Arterial sources of stroke (3) - ans1. Intracranial vascular disease
2. Carotid vascular disease
3. Aortic arch
Characteristics of a thrombotic stroke - ansType most often signaled by TIAs, commonly occurs during or after sleep, strong
association with hypertension
Characteristics of embolic stroke - ansOnset unrelated to activity, quick onset and resolution, associated with endocardial disorders
Characteristics of intracerebral hemorrhage - ansRupture of atherosclerotic vessels, carries the poorest prognosis, creates mass
that compresses the brain
Characteristics of subarachnoid hemorrhage - ansHigh initial mortality, symptoms of meningeal irritation, caused by rupture of
intracranial aneurysm, associated with sudden, severe headache
VERSION VERIFIED RATIONALE GRADED A+
A patient is admitted to the hospital with a left hemiplegia. To determine the size and location and to ascertain whether a stroke is
ischemic or hemorrhagic, the nurse anticipates that the health care provider will request a
a. CT scan
b. lumbar puncture
c. cerebral arteriogram
d. positron emission tomography (PET) - ansA: CT scan- A CT scan is the most commonly used diagnostic test to determine the
size and location of the lesion and to differentiate a thrombotic stroke from a hemorrhagic stroke. Positron emission tomography
(PET) will show the metabolic activity of the brain and provide a depiction of the extent of tissue damage after a stroke. Lumbar
punctures are not performed routinely because of the chance of increased intracranial pressure causing herniation. Cerebral
arteriograms are invasive and may dislodge an embolism or cause further hemorrhage; they are performed only when no other test
can provide the needed information.
A patient with a stroke has a right sided hemiplegia. The nurse prepares family members to help control behavior changes seen with
this type of stroke by teaching them to
a. ignore undesirable behaviors manifested by the patient
b. provide directions to the patient verbally in small steps
c. distract the patient from inappropriate emotional responses
d. supervise all activities before allowing the patient to pursue them independently - ansC: Distract the patient from inappropriate
emotional responses- patients with left-sided brain damage from stroke often experience emotional lability, inappropriate emotional
responses, mood swings, and uncontrolled tears or laughter disproportionate or out of context with the situation. The behavior is
upsetting and embarrassing to both the patient and the family, and the patient should be distracted to minimize its presence.
Patients with right-brain damage often have impulsive, rapid behavior that supervision and direction.
A patient with right hemisphere stroke has a nursing diagnosis of unilateral neglect related to sensory perceptual deficits. During the
patient's rehabilitation, it is important for the nurse to
a. avoid positioning the patient on the affected side
b. place all objects for care on the patient's unaffected side
c. teach the patient to care consciously for the affected side
d. protect the affected side from injury with pillows and supports - ansC: Teach the patient to care consciously for the affected side-
unilateral neglect, or neglect syndrome, occurs when the patient with a stroke is unaware of the affected side of the body, which puts
the patient at risk for injury. During the acute phase, the affected side is cared for by the nurse with positioning and support, during
rehabilitation the patient is taught to care consciously for and attend to the affected side of the body to protect it from injury. Patients
may be positioned on the affected side for up to 30 minutes.
A patient's wife asks the nurse why her husband did not receive the clot busting medication (tPA) she has been reading about. Her
husband is diagnosed with a hemorrhagic stroke. What should the nurse respond?
a. He didn't arrive within the time frame for that therapy
b. Not every is eligible for this drug. Has he had surgery lately?
c. You should discuss the treatment of your husband with your doctor
, NCLEX MED SURG STROKE AND ANSWERS 2024
VERSION VERIFIED RATIONALE GRADED A+
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.
A thrombus that develops in a cerebral artery does not always cause a loss of neurologic function because
a. the body can dissolve the atherosclerotic plaques as they form
b. some tissues of the brain do not require constant blood supply to prevent damage
c. circulation through the circle of Willis may provide blood supply to the affected area of the brain
d. neurologic deficits occur only when major arteries are occluded by thrombus formation around an atherosclerotic plaque - ansC:
Circulation through the circle of Willis may provide blood supply to the affected area of the brain.
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.
An appropriate food for a patient with a stroke who has mild dysphagia is
a. fruit juices
b. pureed meat
c. scrambled eggs
d. fortified milkshakes - ansC: scrambled eggs- soft foods that provide enough texture, flavor, and bulk to stimulate swallowing
should be used for the patient with dysphasia. Thin liquids are difficult to swallow, and patients may not be able to control them in
the mouth. Pureed foods are often too bland and to smooth, and milk products should be avoided because they tend to increase the
viscosity of mucus and increase salivation.
Arterial sources of stroke (3) - ans1. Intracranial vascular disease
2. Carotid vascular disease
3. Aortic arch
Characteristics of a thrombotic stroke - ansType most often signaled by TIAs, commonly occurs during or after sleep, strong
association with hypertension
Characteristics of embolic stroke - ansOnset unrelated to activity, quick onset and resolution, associated with endocardial disorders
Characteristics of intracerebral hemorrhage - ansRupture of atherosclerotic vessels, carries the poorest prognosis, creates mass
that compresses the brain
Characteristics of subarachnoid hemorrhage - ansHigh initial mortality, symptoms of meningeal irritation, caused by rupture of
intracranial aneurysm, associated with sudden, severe headache
