STROKE- NCLEX Detailed Questions And Expert 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 - ANS 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
,STROKE- NCLEX Detailed Questions And Expert Answers
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. - ANS 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.
,STROKE- NCLEX Detailed Questions And Expert Answers
Which disturbance results in loss of half of the visual field?
, STROKE- NCLEX Detailed Questions And Expert Answers
a) Anisocoria
b) Homonymous hemianopsia
c) Nystagmus
d) Diplopia - ANS 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.
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 - ANS 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
,STROKE- NCLEX Detailed Questions And Expert Answers
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. - ANS 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.
,STROKE- NCLEX Detailed Questions And Expert Answers
Which disturbance results in loss of half of the visual field?
, STROKE- NCLEX Detailed Questions And Expert Answers
a) Anisocoria
b) Homonymous hemianopsia
c) Nystagmus
d) Diplopia - ANS 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.
