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NUR 445 FINAL Exam ALL QUESTIONS AND CORRECT
ANSWERS LATEST UPDATE THIS YEAR NEW!!
QUESTION: A patient who had a stroke has decreased level of consciousness, headache, and is
vomiting. Using this information, which nursing diagnosis should the nurse assign?
1. Impaired Skin Integrity
2. Acute Pain
3. Decreased Intracranial Adaptive Capacity
4. Activity Intolerance - ANSWER-Answer: 3
QUESTION: A client is receiving an infusion of tPA for treatment of acute ischemic stroke. The
nurse would immediately discontinue this infusion if the client manifested which assessment
finding? (Select all that apply.)
1. Nausea
2. Severe headache
3. Elevation of blood pressure to 180/100
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4. Atrial fibrillation
5. Decrease in pedal pulse amplitude - ANSWER-Answer: 1, 2, 3, 5
QUESTION: A client being treated for an ischemic stroke has vital signs of temperature: 39.0°C
(102.2°F), blood pressure 160/90 mmHg, heart rate 98 bpm, and respirations 16 bpm. What
action should the nurse take? (Select all that apply.)
1. Continue to monitor
2. Treat the temperature according to protocol
3. STAT page the provider regarding the blood pressure
4. Increase the client's oxygen delivery
5. Accept these vital signs as normal for the client after ischemic stroke - ANSWER-Answer: 1, 2
QUESTION: The wife of a client who had a stroke says, "I'll never be able to care for him at
home unless he can help me. When will therapy start to help him with walking?" Which answer,
made by the nurse, is most appropriate?
1. "Most stroke clients don't rebuild enough strength to help with their care."
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2. "The physical therapist will make that determination, and I'm certain they will talk with you
about it then."
3. "When he has some leg strength and balance back, we will start helping him learn to walk
again."
4. "As soon as his vital signs are stable, we will start walking therapy." - ANSWER-Answer: 3
QUESTION: A client was just admitted for treatment of stroke. Assessment reveals a well-
nourished 63-year-old male with left-sided weakness, a weak gag reflex, and difficulty
swallowing. The nurse would anticipate initiating nutritional support for this client if he is
unable to take oral nourishment by which time?
1. Within 24 hours of discontinuation of IV therapy
2. Within 2 days of return of gag reflex
3. Within 5 days of admission
4. Within 12 hours of diagnosis - ANSWER-Answer: 3
QUESTION: The nurse is caring for a client who has right-sided weakness and Broca's aphasia
following a stroke that occurred 36 hours ago. Which assessment instruction should the nurse
use with this client?
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1. "Tell me what you were doing immediately before your illness."
2. "Can you see anything at all out of your bad eye?"
3. "Lift your unaffected arm up as much as you can."
4. "Describe the sensations you have in your good leg." - ANSWER-Answer: 3
QUESTION: A client is admitted after being struck in the right side of the head with a baseball
bat. An MRI shows the presence of focal injury and DAI. Which mechanism of injury is likely to
have occurred?
1. Acceleration
2. Deceleration
3. Rotational
4. Penetrating - ANSWER-Answer: 3
QUESTION: A client was admitted to the emergency department after a traumatic brain injury.
Current assessment included a decrease in Glasgow Coma Scale by one point and development
of a fixed and dilated pupil. What should the nurse do first?
1. Plan to reassess the client in 15 minutes.
4
NUR 445 FINAL Exam ALL QUESTIONS AND CORRECT
ANSWERS LATEST UPDATE THIS YEAR NEW!!
QUESTION: A patient who had a stroke has decreased level of consciousness, headache, and is
vomiting. Using this information, which nursing diagnosis should the nurse assign?
1. Impaired Skin Integrity
2. Acute Pain
3. Decreased Intracranial Adaptive Capacity
4. Activity Intolerance - ANSWER-Answer: 3
QUESTION: A client is receiving an infusion of tPA for treatment of acute ischemic stroke. The
nurse would immediately discontinue this infusion if the client manifested which assessment
finding? (Select all that apply.)
1. Nausea
2. Severe headache
3. Elevation of blood pressure to 180/100
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4. Atrial fibrillation
5. Decrease in pedal pulse amplitude - ANSWER-Answer: 1, 2, 3, 5
QUESTION: A client being treated for an ischemic stroke has vital signs of temperature: 39.0°C
(102.2°F), blood pressure 160/90 mmHg, heart rate 98 bpm, and respirations 16 bpm. What
action should the nurse take? (Select all that apply.)
1. Continue to monitor
2. Treat the temperature according to protocol
3. STAT page the provider regarding the blood pressure
4. Increase the client's oxygen delivery
5. Accept these vital signs as normal for the client after ischemic stroke - ANSWER-Answer: 1, 2
QUESTION: The wife of a client who had a stroke says, "I'll never be able to care for him at
home unless he can help me. When will therapy start to help him with walking?" Which answer,
made by the nurse, is most appropriate?
1. "Most stroke clients don't rebuild enough strength to help with their care."
2
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2. "The physical therapist will make that determination, and I'm certain they will talk with you
about it then."
3. "When he has some leg strength and balance back, we will start helping him learn to walk
again."
4. "As soon as his vital signs are stable, we will start walking therapy." - ANSWER-Answer: 3
QUESTION: A client was just admitted for treatment of stroke. Assessment reveals a well-
nourished 63-year-old male with left-sided weakness, a weak gag reflex, and difficulty
swallowing. The nurse would anticipate initiating nutritional support for this client if he is
unable to take oral nourishment by which time?
1. Within 24 hours of discontinuation of IV therapy
2. Within 2 days of return of gag reflex
3. Within 5 days of admission
4. Within 12 hours of diagnosis - ANSWER-Answer: 3
QUESTION: The nurse is caring for a client who has right-sided weakness and Broca's aphasia
following a stroke that occurred 36 hours ago. Which assessment instruction should the nurse
use with this client?
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1. "Tell me what you were doing immediately before your illness."
2. "Can you see anything at all out of your bad eye?"
3. "Lift your unaffected arm up as much as you can."
4. "Describe the sensations you have in your good leg." - ANSWER-Answer: 3
QUESTION: A client is admitted after being struck in the right side of the head with a baseball
bat. An MRI shows the presence of focal injury and DAI. Which mechanism of injury is likely to
have occurred?
1. Acceleration
2. Deceleration
3. Rotational
4. Penetrating - ANSWER-Answer: 3
QUESTION: A client was admitted to the emergency department after a traumatic brain injury.
Current assessment included a decrease in Glasgow Coma Scale by one point and development
of a fixed and dilated pupil. What should the nurse do first?
1. Plan to reassess the client in 15 minutes.
4
