NCLEX STROKE EXAM 2025\2026 NEWEST
UPDATED QUESTIONS AND ANSWERS.
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 - CorreCt Answers -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. - CorreCt Answers -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 - CorreCt Answers -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. - CorreCt Answers -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 - CorreCt Answers -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.
UPDATED QUESTIONS AND ANSWERS.
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 - CorreCt Answers -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. - CorreCt Answers -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 - CorreCt Answers -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. - CorreCt Answers -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 - CorreCt Answers -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.
