1. Ans: C
1. A patient has had an ischemic stroke Feedback:
and has been admitted to the medical
unit. What action should the nurse per- A pillow in the axilla prevents adduc-
form to best prevent joint deformities? tion of the affected shoulder and keeps
A) Place the patient in the prone position the arm away from the chest. The prone
for 30 minutes/day. position with a pillow under the pelvis,
B) Assist the patient in acutely flexing the not flat, promotes hyperextension of the
thigh to promote movement. hip joints, essential for normal gait. To
C) Place a pillow in the axilla when there promote venous return and prevent ede-
is limited external rotation. ma, the upper thigh should not be flexed
D) Place patient's hand in pronation. acutely. The hand is placed in slight
supination, not pronation, which is its
most functional position.
2. Ans: C
2. A patient diagnosed with transient is-
Feedback:
chemic attacks (TIAs) is scheduled for
a carotid endarterectomy. The nurse ex-
The main surgical procedure for select
plains that this procedure will be done for
patients with TIAs is carotid endarterec-
what purpose?
tomy, the removal of an atherosclerot-
A) To decrease cerebral edema
ic plaque or thrombus from the carotid
B) To prevent seizure activity that is com-
artery to prevent stroke in
mon following a TIA
patients with occlusive disease of the
C) To remove atherosclerotic plaques
extracranial arteries. An endarterectomy
blocking cerebral flow
does not decrease cerebral edema, pre-
D) To determine the cause of the TIA
vent seizure activity, or determine the
cause of a TIA.
3. Ans: C
3. The nurse is discharging home a pa-
tient who suffered a stroke. He has a flac- Feedback:
cid right arm and leg and is experiencing
problems with urinary incontinence. The Depression is a common and serious
nurse makes a referral to a home health problem in the patient who has had a
nurse because of an awareness of what stroke. It can result from a profound dis-
common patient response to a change in ruption in his or her life and changes in
total function, leaving the patient with a
, loss of independence. The nurse needs
body image? to encourage the patient to verbalize feel-
A) Denial ings to assess the effect of the stroke on
B) Fear self-esteem. Denial, fear, and disassoci-
C) Depression ation are not the most common patient
D) Disassociation response to a change in body image, al-
though each can occur in some patients.
4. Ans: B
4. When caring for a patient who had
a hemorrhagic stroke, close monitoring
Feedback:
of vital signs and neurologic changes is
imperative. What is the earliest sign of
Alteration in LOC is the earliest sign of
deterioration in a patient with a hemor-
deterioration in a patient after a hemor-
rhagic stroke of which the nurse should
rhagic stroke, such as mild drowsiness,
be aware?
slight slurring of speech, and sluggish
A) Generalized pain
papillary reaction. Sudden headache
B) Alteration in level of consciousness
may occur, but generalized pain is less
(LOC)
common. Seizures and shortness of
C) Tonicclonic seizures
breath are not identified as early signs of
D) Shortness of breath
hemorrhagic stroke.
5. The nurse is performing stroke risk 5. Ans: B
screenings at a hospital open house. The
nurse has identified four patients who Feedback:
might be at risk for a stroke. Which pa-
tient is likely at the highest risk for a Uncontrolled hypertension is the primary
hemorrhagic stroke? cause of a hemorrhagic stroke. Control
A) White female, age 60, with history of of hypertension, especially in individuals
excessive alcohol intake over 55 years of age, clearly reduces the
B) White male, age 60, with history of risk for hemorrhagic stroke. Additional
uncontrolled hypertension risk factors are increased age, male gen-
C) Black male, age 60, with history of der, and excessive alcohol intake. Anoth-
diabetes er high-risk group includes African Amer-
D) Black male, age 50, with history of icans, where the incidence of first stroke
smoking is almost twice that as in Caucasians.
6. Ans: A
Feedback:
, Acute care begins with managing ABCs.
Patients may have difficulty keeping an
6. A patient who just suffered a sus-
open and clear airway secondary to de-
pected ischemic stroke is brought to the
creased LOC. Neurologic assessment
ED by ambulance. On what should the
with close monitoring for signs of in-
nurse's primary assessment focus?
creased neurologic deficit and seizure
A) Cardiac and respiratory status
activity occurs next. Fluid and electrolyte
B) Seizure activity
balance must be controlled carefully with
C) Pain
the goal of adequate hydration to pro-
D) Fluid and electrolyte balance
mote perfusion and decrease further
brain activity.
7. A patient with a cerebral aneurysm 7. Ans: D
exhibits signs and symptoms of an in-
crease in intracranial pressure (ICP). Feedback:
What nursing intervention would be most
appropriate for this patient? The patient is placed on immediate and
A) Range-of-motion exercises to prevent absolute bed rest in a quiet, nonstressful
contractures environment because activity, pain, and
B) Encouraging independence with anxiety elevate BP, which increases the
ADLs to promote recovery risk for bleeding. Visitors are restricted.
C) Early initiation of physical therapy The nurse administers all personal care.
D) Absolute bed rest in a quiet, nonstim- The patient is fed and bathed to prevent
ulating environment any exertion that might raise BP.
8. Ans: D
8. A patient recovering from a stroke has
Feedback:
severe shoulder pain from subluxation of
the shoulder and is being cared for on the
To prevent shoulder pain, the nurse
unit. To prevent further injury and pain,
should never lift a patient by the flac-
the nurse caring for this patient is aware
cid shoulder or pull on the affected
of what principle of care?
arm or shoulder. The patient is taught
A) The patient should be fitted with a
how to move and exercise the affect-
cast because use of a sling should be
ed arm/shoulder through proper move-
avoided due to adduction of the affected
ment and positioning. The patient is in-
shoulder.
structed to interlace the fingers, place
B) Elevation of the arm and hand can
the palms together, and push the clasped
lead to further complications associated
hands slowly forward to bring the scapu-
lae forward; he or she then raises both
1. A patient has had an ischemic stroke Feedback:
and has been admitted to the medical
unit. What action should the nurse per- A pillow in the axilla prevents adduc-
form to best prevent joint deformities? tion of the affected shoulder and keeps
A) Place the patient in the prone position the arm away from the chest. The prone
for 30 minutes/day. position with a pillow under the pelvis,
B) Assist the patient in acutely flexing the not flat, promotes hyperextension of the
thigh to promote movement. hip joints, essential for normal gait. To
C) Place a pillow in the axilla when there promote venous return and prevent ede-
is limited external rotation. ma, the upper thigh should not be flexed
D) Place patient's hand in pronation. acutely. The hand is placed in slight
supination, not pronation, which is its
most functional position.
2. Ans: C
2. A patient diagnosed with transient is-
Feedback:
chemic attacks (TIAs) is scheduled for
a carotid endarterectomy. The nurse ex-
The main surgical procedure for select
plains that this procedure will be done for
patients with TIAs is carotid endarterec-
what purpose?
tomy, the removal of an atherosclerot-
A) To decrease cerebral edema
ic plaque or thrombus from the carotid
B) To prevent seizure activity that is com-
artery to prevent stroke in
mon following a TIA
patients with occlusive disease of the
C) To remove atherosclerotic plaques
extracranial arteries. An endarterectomy
blocking cerebral flow
does not decrease cerebral edema, pre-
D) To determine the cause of the TIA
vent seizure activity, or determine the
cause of a TIA.
3. Ans: C
3. The nurse is discharging home a pa-
tient who suffered a stroke. He has a flac- Feedback:
cid right arm and leg and is experiencing
problems with urinary incontinence. The Depression is a common and serious
nurse makes a referral to a home health problem in the patient who has had a
nurse because of an awareness of what stroke. It can result from a profound dis-
common patient response to a change in ruption in his or her life and changes in
total function, leaving the patient with a
, loss of independence. The nurse needs
body image? to encourage the patient to verbalize feel-
A) Denial ings to assess the effect of the stroke on
B) Fear self-esteem. Denial, fear, and disassoci-
C) Depression ation are not the most common patient
D) Disassociation response to a change in body image, al-
though each can occur in some patients.
4. Ans: B
4. When caring for a patient who had
a hemorrhagic stroke, close monitoring
Feedback:
of vital signs and neurologic changes is
imperative. What is the earliest sign of
Alteration in LOC is the earliest sign of
deterioration in a patient with a hemor-
deterioration in a patient after a hemor-
rhagic stroke of which the nurse should
rhagic stroke, such as mild drowsiness,
be aware?
slight slurring of speech, and sluggish
A) Generalized pain
papillary reaction. Sudden headache
B) Alteration in level of consciousness
may occur, but generalized pain is less
(LOC)
common. Seizures and shortness of
C) Tonicclonic seizures
breath are not identified as early signs of
D) Shortness of breath
hemorrhagic stroke.
5. The nurse is performing stroke risk 5. Ans: B
screenings at a hospital open house. The
nurse has identified four patients who Feedback:
might be at risk for a stroke. Which pa-
tient is likely at the highest risk for a Uncontrolled hypertension is the primary
hemorrhagic stroke? cause of a hemorrhagic stroke. Control
A) White female, age 60, with history of of hypertension, especially in individuals
excessive alcohol intake over 55 years of age, clearly reduces the
B) White male, age 60, with history of risk for hemorrhagic stroke. Additional
uncontrolled hypertension risk factors are increased age, male gen-
C) Black male, age 60, with history of der, and excessive alcohol intake. Anoth-
diabetes er high-risk group includes African Amer-
D) Black male, age 50, with history of icans, where the incidence of first stroke
smoking is almost twice that as in Caucasians.
6. Ans: A
Feedback:
, Acute care begins with managing ABCs.
Patients may have difficulty keeping an
6. A patient who just suffered a sus-
open and clear airway secondary to de-
pected ischemic stroke is brought to the
creased LOC. Neurologic assessment
ED by ambulance. On what should the
with close monitoring for signs of in-
nurse's primary assessment focus?
creased neurologic deficit and seizure
A) Cardiac and respiratory status
activity occurs next. Fluid and electrolyte
B) Seizure activity
balance must be controlled carefully with
C) Pain
the goal of adequate hydration to pro-
D) Fluid and electrolyte balance
mote perfusion and decrease further
brain activity.
7. A patient with a cerebral aneurysm 7. Ans: D
exhibits signs and symptoms of an in-
crease in intracranial pressure (ICP). Feedback:
What nursing intervention would be most
appropriate for this patient? The patient is placed on immediate and
A) Range-of-motion exercises to prevent absolute bed rest in a quiet, nonstressful
contractures environment because activity, pain, and
B) Encouraging independence with anxiety elevate BP, which increases the
ADLs to promote recovery risk for bleeding. Visitors are restricted.
C) Early initiation of physical therapy The nurse administers all personal care.
D) Absolute bed rest in a quiet, nonstim- The patient is fed and bathed to prevent
ulating environment any exertion that might raise BP.
8. Ans: D
8. A patient recovering from a stroke has
Feedback:
severe shoulder pain from subluxation of
the shoulder and is being cared for on the
To prevent shoulder pain, the nurse
unit. To prevent further injury and pain,
should never lift a patient by the flac-
the nurse caring for this patient is aware
cid shoulder or pull on the affected
of what principle of care?
arm or shoulder. The patient is taught
A) The patient should be fitted with a
how to move and exercise the affect-
cast because use of a sling should be
ed arm/shoulder through proper move-
avoided due to adduction of the affected
ment and positioning. The patient is in-
shoulder.
structed to interlace the fingers, place
B) Elevation of the arm and hand can
the palms together, and push the clasped
lead to further complications associated
hands slowly forward to bring the scapu-
lae forward; he or she then raises both
