WITH 100% CORRECT ANSWERS
The nurse is preparing health education for a patient who is being discharged after
hospitalization for a hemorrhagic stroke. What content should the nurse include in this
education?
A) Mild, intermittent seizures can be expected.
B) Take ibuprofen for complaints of a serious headache.
C) Take antihypertensive medication as ordered.
D) Drowsiness is normal for the first week after discharge. - Answer-C) Take
antihypertensive medication as ordered.
A patient diagnosed with a cerebral aneurysm reports a severe headache to the nurse.
What action is a priority for the nurse?
A) Sit with the patient for a few minutes.
B) Administer an analgesic.
C) Inform the nurse-manager.
D) Call the physician immediately. - Answer-D) Call the physician immediately.
A patient is brought by ambulance to the ED after suffering what the family thinks is a
stroke. The nurse caring for this patient is aware that an absolute contraindication for
thrombolytic therapy is what?
A) Evidence of hemorrhagic stroke
B) Blood pressure of 180/110 mm Hg
C) Evidence of stroke evolution
D) Previous thrombolytic therapy within the past 12 months - Answer-A) Evidence of
hemorrhagic stroke
When caring for a patient who has had a stroke, a priority is reduction of ICP. What
patient position is most consistent with this goal?
A) Head turned slightly to the right side
B) Elevation of the head of the bed
C) Position changes every 15 minutes while awake
D) Extension of the neck - Answer-B) Elevation of the head of the bed
A patient who suffered an ischemic stroke now has disturbed sensory perception. What
principle should guide the nurse's care of this patient?
A) The patient should be approached on the side where visual perception is intact.
B) Attention to the affected side should be minimized in order to decrease anxiety.
,C) The patient should avoid turning in the direction of the defective visual field to
minimize shoulder subluxation.
D) The patient should be approached on the opposite side of where the visual
perception is intact to promote recovery. - Answer-A) The patient should be approached
on the side where visual perception is intact.
What should be included in the patient's care plan when establishing an exercise
program for a patient affected by a stroke?
A) Schedule passive range of motion every other day.
B) Keep activity limited, as the patient may be over stimulated.
C) Have the patient perform active range-of-motion (ROM) exercises once a day.
D) Exercise the affected extremities passively four or five times a day. - Answer-D)
Exercise the affected extremities passively four or five times a day.
A female patient is diagnosed with a right-sided stroke. The patient is now experiencing
hemianopsia. How might the nurse help the patient manage her potential sensory and
perceptional difficulties?
A) Keep the lighting in the patient's room low.
B) Place the patient's clock on the affected side.
C) Approach the patient on the side where vision is impaired.
D) Place the patient's extremities where she can see them. - Answer-D) Place the
patient's extremities where she can see them.
The public health nurse is planning a health promotion campaign that reflects current
epidemiologic trends. The nurse should know that hemorrhagic stroke currently
accounts for what percentage of total strokes in the United States?
A) 43%
B) 33%
C) 23%
D) 13% - Answer-D) 13%
A patient who has experienced an ischemic stroke has been admitted to the medical
unit. The patient's family in adamant that she remain on bed rest to hasten her recovery
and to conserve energy. What principle of care should inform the nurse's response to
the family?
A) The patient should mobilize as soon as she is physically able.
B) To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks.
C) The patient should remain on bed rest until she expresses a desire to mobilize.
D) Lack of mobility will greatly increase the patient's risk of stroke recurrence. - Answer-
A) The patient should mobilize as soon as she is physically able.
A patient has recently begun mobilizing during the recovery from an ischemic stroke. To
protect the patient's safety during mobilization, the nurse should perform what action?
A) Support the patient's full body weight with a waist belt during ambulation.
B) Have a colleague follow the patient closely with a wheelchair.
C) Avoid mobilizing the patient in the early morning or late evening.
,D) Ensure that the patient's family members do not participate in mobilization. - Answer-
B) Have a colleague follow the patient closely with a wheelchair.
A patient diagnosed with a hemorrhagic stroke has been admitted to the neurologic
ICU. The nurse knows that teaching for the patient and family needs to begin as soon
as the patient is settled on the unit and will continue until the patient is discharged. What
will family education need to include?
A) How to differentiate between hemorrhagic and ischemic stroke
B) Risk factors for ischemic stroke
C) How to correctly modify the home environment
D) Techniques for adjusting the patient's medication dosages at home - Answer-C) How
to correctly modify the home environment
After a subarachnoid hemorrhage, the patient's laboratory results indicate a serum
sodium level of less than 126 mEq/L. What is the nurse's most appropriate action?
A) Administer a bolus of normal saline as ordered.
B) Prepare the patient for thrombolytic therapy as ordered.
C) Facilitate testing for hypothalamic dysfunction.
D) Prepare to administer 3% NaCl by IV as ordered. - Answer-D) Prepare to administer
3% NaCl by IV as ordered.
The nurse is caring for a patient with a history of transient ischemic attacks (TIAs) and
moderate carotid stenosis who has undergone a carotid endarterectomy. Which of the
following postoperative findings would cause the nurse the most concern?
a) Blood pressure (BP): 128/86 mm Hg
b) Neck pain: 3/10 (0 to 10 pain scale)
c) Mild neck edema
d) Difficulty swallowing - Answer-Difficulty swallowing
The patient's inability to swallow without difficulty would cause the nurse the most
concern. Difficulty in swallowing, hoarseness or other signs of cranial nerve dysfunction
must be assessed. The nurse focuses on assessment of the following cranial nerves:
facial (VII), vagus (X), spinal accessory (XI), and hypoglossal (XII). Some edema in the
neck after surgery is expected; however, extensive edema and hematoma formation
can obstruct the airway. Emergency airway supplies, including those needed for a
tracheostomy, must be available. The patient's neck pain and mild BP elevation need
addressing but would not cause the nurse the most concern. Hypotension is avoided to
prevent cerebral ischemia and thrombosis. Uncontrolled hypertension may precipitate
cerebral hemorrhage, edema, hemorrhage at the surgical incision, or disruption of the
arterial reconstruction.
, 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.