NUR242 MED SURG EXAM 4 2026 FULL
PREPARATION WITH CORRECT ANSWERS
◉ Which is the priority nursing action for a client admitted to the
hospital in a coma after having a stroke? Answer: Maintain an open
airway.
◉ Which position would the nurse plan to use for the client who is
having a hypertensive crisis and evolving stroke? Answer: Side-lying
◉ Which nursing action is essential when a client experiences
hemianopsia as the result of a left ischemic stroke? Answer: Place
objects within the visual field
◉ Initially after a stroke, a client's pupils are equal and reactive to
light. Later, the nurse assesses that the right pupil is reacting more
slowly than the left and that the systolic blood pressure is rising.
Which complication would the nurse plan to address? Answer:
Increased intracranial pressure
◉ The registered nurse (RN) is caring for a client who is currently
hospitalized for a stroke. Which professional management strategy
will be most effective for the RN to improve the safety and quality of
client care? Answer: Delegation
,◉ The client taking intravenous coagulant medications for a
bleeding disorder suddenly develops an embolic stroke as a result of
medication overdose. Which actions by the hospital management
does the Leapfrog Group suggest? Select all that apply. One, some, or
all responses may be correct. Answer: Apologize to the client and
family.
Waive all costs directly related to the adverse effect.
Report the adverse event to The Joint Commission.
◉ Which action will the nurse complete when preparing a stroke
client for cerebral imaging with iodine-based contrast dye? Answer:
Ensure a recent creatinine level has been assessed.
◉ Which behaviors would the nurse include when teaching a family
what to expect from a client who experienced a stroke on the left
side of the brain? Select all that apply. One, some, or all responses
may be correct. Answer: Slow performance and caution
Impaired speech/language aphasias
Awareness of deficits with depression and anxiety
◉ When a client has difficulty swallowing after a stroke, which
action by the nurse would be most important in preventing
pneumonia? Answer: Having suction available during meals
,◉ A client has had a recent brain attack (cerebrovascular
accident/stroke). Which preventative would the nurse anticipate
will be prescribed daily to avoid straining due to constipation?
Answer: Stool softener
◉ Which intervention would the disaster management team nurse
perform for the survivors of an explosion who developed heat
stroke? Answer: Apply ice packs on the client's scalp
◉ Which level of care is the nurse providing when preparing to
discharge a client who is learning to walk again after a stroke to a
rehabilitation center? Answer: tertiary care
◉ Which action by the emergency department nurse is the priority
for a client with heat stroke? Answer: Assess the airway and
breathing
◉ A client who sustains a stroke has a loss of proprioception and
fine touch. Which artery would the nurse suspect is damaged?
Answer: Anterior cerebral
◉ A client has a brain attack (stroke) that involves the right cerebral
cortex and cranial nerves. Which areas of paralysis would the nurse
expect to find upon assessment? Select all that apply. One, some, or
all responses may be correct. Answer: Left leg
, Left arm
Left side of face
◉ Initially after a stroke, the client's pupils are equal and reactive to
light. Four hours later, the nurse identifies that one pupil reacts
more slowly than the other and the client's systolic blood pressure is
increasing. For which condition would the nurse prepare to
intervene? Answer: Increased intracranial pressure
◉ The nurse observes dorsiflexion of the big toe and fanning of
other toes when the lateral side of a client's foot is stroked. Which
finding would the nurse document? Answer: Exhibits a positive
Babinski sign
◉ The nurse is caring for a client who had a stroke and who has
varying moods ranging from anger to depression to concern about
the aphasia, hemiparesis, and the gavage feedings. Which behavior
indicates the client's acceptance of physical limitations? Answer:
Performs tube feedings without assistance
◉ A client has dysarthria after a stroke. Which goal would the nurse
include in the plan of care to address this problem? Answer:
Effective communication
PREPARATION WITH CORRECT ANSWERS
◉ Which is the priority nursing action for a client admitted to the
hospital in a coma after having a stroke? Answer: Maintain an open
airway.
◉ Which position would the nurse plan to use for the client who is
having a hypertensive crisis and evolving stroke? Answer: Side-lying
◉ Which nursing action is essential when a client experiences
hemianopsia as the result of a left ischemic stroke? Answer: Place
objects within the visual field
◉ Initially after a stroke, a client's pupils are equal and reactive to
light. Later, the nurse assesses that the right pupil is reacting more
slowly than the left and that the systolic blood pressure is rising.
Which complication would the nurse plan to address? Answer:
Increased intracranial pressure
◉ The registered nurse (RN) is caring for a client who is currently
hospitalized for a stroke. Which professional management strategy
will be most effective for the RN to improve the safety and quality of
client care? Answer: Delegation
,◉ The client taking intravenous coagulant medications for a
bleeding disorder suddenly develops an embolic stroke as a result of
medication overdose. Which actions by the hospital management
does the Leapfrog Group suggest? Select all that apply. One, some, or
all responses may be correct. Answer: Apologize to the client and
family.
Waive all costs directly related to the adverse effect.
Report the adverse event to The Joint Commission.
◉ Which action will the nurse complete when preparing a stroke
client for cerebral imaging with iodine-based contrast dye? Answer:
Ensure a recent creatinine level has been assessed.
◉ Which behaviors would the nurse include when teaching a family
what to expect from a client who experienced a stroke on the left
side of the brain? Select all that apply. One, some, or all responses
may be correct. Answer: Slow performance and caution
Impaired speech/language aphasias
Awareness of deficits with depression and anxiety
◉ When a client has difficulty swallowing after a stroke, which
action by the nurse would be most important in preventing
pneumonia? Answer: Having suction available during meals
,◉ A client has had a recent brain attack (cerebrovascular
accident/stroke). Which preventative would the nurse anticipate
will be prescribed daily to avoid straining due to constipation?
Answer: Stool softener
◉ Which intervention would the disaster management team nurse
perform for the survivors of an explosion who developed heat
stroke? Answer: Apply ice packs on the client's scalp
◉ Which level of care is the nurse providing when preparing to
discharge a client who is learning to walk again after a stroke to a
rehabilitation center? Answer: tertiary care
◉ Which action by the emergency department nurse is the priority
for a client with heat stroke? Answer: Assess the airway and
breathing
◉ A client who sustains a stroke has a loss of proprioception and
fine touch. Which artery would the nurse suspect is damaged?
Answer: Anterior cerebral
◉ A client has a brain attack (stroke) that involves the right cerebral
cortex and cranial nerves. Which areas of paralysis would the nurse
expect to find upon assessment? Select all that apply. One, some, or
all responses may be correct. Answer: Left leg
, Left arm
Left side of face
◉ Initially after a stroke, the client's pupils are equal and reactive to
light. Four hours later, the nurse identifies that one pupil reacts
more slowly than the other and the client's systolic blood pressure is
increasing. For which condition would the nurse prepare to
intervene? Answer: Increased intracranial pressure
◉ The nurse observes dorsiflexion of the big toe and fanning of
other toes when the lateral side of a client's foot is stroked. Which
finding would the nurse document? Answer: Exhibits a positive
Babinski sign
◉ The nurse is caring for a client who had a stroke and who has
varying moods ranging from anger to depression to concern about
the aphasia, hemiparesis, and the gavage feedings. Which behavior
indicates the client's acceptance of physical limitations? Answer:
Performs tube feedings without assistance
◉ A client has dysarthria after a stroke. Which goal would the nurse
include in the plan of care to address this problem? Answer:
Effective communication
