STROKE NCLEX, STROKE NCLEX
QUESTIONS, STROKE NCLEX
QUESTIONS, PRACTICE QUESTIONS:
WEEK 11
After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual
effects, the nurse anticipates teaching the patient about
a. cerebral aneurysm clipping.
b. heparin intravenous infusion.
c. oral low-dose aspirin therapy.
d. tissue plasminogen activator (tape). - ANSWER - C. The patient's symptoms are consistent
with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed
after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with
acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm.
tape is used only for acute ischemic stroke, not for TIA.
A 68-year-old patient is being admitted with a possible stroke. Which information from the
assessment indicates that the nurse should consult with the health care provider before giving
the prescribed aspirin?
a. The patient has dysphasia.
b. The patient has atrial fibrillation.
c. The patient reports that symptoms began with a severe headache.
d. The patient has a history of brief episodes of right-sided hemiplegia. - ANSWER - C. A sudden
onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial
fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin
use, so the nurse can administer the aspirin.
A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided
arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse
expect to find?
,a. Impulsive behavior
b. Right-sided neglect
c. Hyperactive left-sided tendon reflexes
d. Difficulty comprehending instructions - ANSWER - D. Right-sided paralysis indicates a left-
brain stroke, which will lead to difficulty with comprehension and use of language. The left-side
reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side
stroke.
During the change of shift report a nurse is told that a patient has an occluded left posterior
cerebral artery. The nurse will anticipate that the patient may have
a. dysphasia.
b. confusion.
c. visual deficits.
d. poor judgment. - ANSWER - C. Visual disturbances are expected with posterior cerebral
artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and
changes in judgment are more typical of anterior cerebral artery occlusion.
When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral
atherosclerosis
a. to monitor and record the blood pressure daily.
b. that Plavix will dissolve clots in the cerebral arteries.
c. that Plavix will reduce cerebral artery plaque formation.
d. to call the health care provider if stools are bloody or tarry. - ANSWER - D. Clopidogrel
(Plavix) inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients
should be advised to notify the health care provider about any signs of bleeding. The
medication does not lower blood pressure, decrease plaque formation, or dissolve clots.
A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy.
Which response by the nurse is accurate?
a. "The obstructing plaque is surgically removed from an artery in the neck."
b. "The diseased portion of the artery in the brain is replaced with a synthetic graft."
,c. "A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots
are removed."
d. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is
inflated to flatten the plaque." - ANSWER - A. In a carotid endarterectomy, the carotid artery is
incised and the plaque is removed. The response beginning, "The diseased portion of the artery
in the brain is replaced" describes an arterial graft procedure. The answer beginning, "A
catheter with a deflated balloon is positioned at the narrow area" describes an angioplasty. The
final response beginning, "A wire is threaded through the artery" describes the mechanical
embolus removal in cerebral ischemia (MERCI) procedure.
A patient admitted with possible stroke has been aphasic for 3 hours and his current blood
pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse
question?
a. Keep head of bed elevated at least 30 degrees.
b. Infuse normal saline intravenously at 75 mL/hr.
c. Administer tissue plasminogen activator (tape) per protocol.
d. Administer a labetalol (Norm dyne) drip to keep BP less than 140/90 mm Hg. - ANSWER - D.
Because elevated BP may be a protective response to maintain cerebral perfusion,
antihypertensive therapy is recommended only if mean arterial pressure (MAP) is >130 mm Hg
or systolic pressure is >220 mm Hg. Fluid intake should be 1500 to 2000 mL daily to maintain
cerebral blood flow. The head of the bed should be elevated to at least 30 degrees, unless the
patient has symptoms of poor tissue perfusion. tape may be administered if the patient meets
the other criteria for tape use.
A 56-year-old patient arrives in the emergency department with hemiparesis and dysarthria
that started 2 hours previously, and health records show a history of several transient ischemic
attacks (TIAs). The nurse anticipates preparing the patient for
a. surgical endarterectomy.
b. transluminal angioplasty.
c. intravenous heparin administration.
d. tissue plasminogen activator (tape) infusion. - ANSWER - D. The patient's history and clinical
manifestations suggest an acute ischemic stroke and a patient who is seen within 4.5 hours of
stroke onset is likely to receive tape (after screening with a CT scan). Heparin administration in
, the emergency phase is not indicated. Emergent carotid transluminal angioplasty or
endarterectomy is not indicated for the patient who is having an acute ischemic stroke.
A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse identifies
the nursing diagnosis of impaired verbal communication. An appropriate nursing intervention
to help the patient communicate is to
a. asks questions that the patient can answer with "yes" or "no."
b. develops a list of words that the patient can read and practice reciting.
c. has the patient practice her facial and tongue exercises with a mirror.
d. prevents embarrassing the patient by answering for her if she does not respond. - ANSWER -
A. Communication will be facilitated and less frustrating to the patient when questions that
require a "yes" or "no" response are used. When the language areas of the brain are injured,
the patient might not be able to read or recite words, which will frustrate the patient without
improving communication. Expressive aphasia is caused by damage to the language areas of the
brain, not by the areas that control the motor aspects of speech. The nurse should allow time
for the patient to respond.
A 72-year-old patient who has a history of a transient ischemic attack (TIA) has an order for
aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't
need the aspirin today. I don't have a fever." Which action should the nurse take?
a. Document that the aspirin was refused by the patient.
b. Tell the patient that the aspirin is used to prevent a fever.
c. Explain that the aspirin is ordered to decrease stroke risk.
d. Call the health care provider to clarify the medication order. - ANSWER - C. Aspirin is ordered
to prevent stroke in patients who have experienced TIAs. Documentation of the patient's
refusal to take the medication is an inadequate response by the nurse. There is no need to
clarify the order with the health care provider. The aspirin is not ordered to prevent aches and
pains.
For a patient who had a right hemisphere stroke the nurse establishes a nursing diagnosis of
a. risk for injury related to denial of deficits and impulsiveness.
b. impaired physical mobility related to right-sided hemiplegia.
QUESTIONS, STROKE NCLEX
QUESTIONS, PRACTICE QUESTIONS:
WEEK 11
After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual
effects, the nurse anticipates teaching the patient about
a. cerebral aneurysm clipping.
b. heparin intravenous infusion.
c. oral low-dose aspirin therapy.
d. tissue plasminogen activator (tape). - ANSWER - C. The patient's symptoms are consistent
with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed
after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with
acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm.
tape is used only for acute ischemic stroke, not for TIA.
A 68-year-old patient is being admitted with a possible stroke. Which information from the
assessment indicates that the nurse should consult with the health care provider before giving
the prescribed aspirin?
a. The patient has dysphasia.
b. The patient has atrial fibrillation.
c. The patient reports that symptoms began with a severe headache.
d. The patient has a history of brief episodes of right-sided hemiplegia. - ANSWER - C. A sudden
onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial
fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin
use, so the nurse can administer the aspirin.
A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided
arm and leg paralysis. When admitting the patient, which clinical manifestation will the nurse
expect to find?
,a. Impulsive behavior
b. Right-sided neglect
c. Hyperactive left-sided tendon reflexes
d. Difficulty comprehending instructions - ANSWER - D. Right-sided paralysis indicates a left-
brain stroke, which will lead to difficulty with comprehension and use of language. The left-side
reflexes are likely to be intact. Impulsive behavior and neglect are more likely with a right-side
stroke.
During the change of shift report a nurse is told that a patient has an occluded left posterior
cerebral artery. The nurse will anticipate that the patient may have
a. dysphasia.
b. confusion.
c. visual deficits.
d. poor judgment. - ANSWER - C. Visual disturbances are expected with posterior cerebral
artery occlusion. Aphasia occurs with middle cerebral artery involvement. Cognitive deficits and
changes in judgment are more typical of anterior cerebral artery occlusion.
When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral
atherosclerosis
a. to monitor and record the blood pressure daily.
b. that Plavix will dissolve clots in the cerebral arteries.
c. that Plavix will reduce cerebral artery plaque formation.
d. to call the health care provider if stools are bloody or tarry. - ANSWER - D. Clopidogrel
(Plavix) inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients
should be advised to notify the health care provider about any signs of bleeding. The
medication does not lower blood pressure, decrease plaque formation, or dissolve clots.
A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy.
Which response by the nurse is accurate?
a. "The obstructing plaque is surgically removed from an artery in the neck."
b. "The diseased portion of the artery in the brain is replaced with a synthetic graft."
,c. "A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots
are removed."
d. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is
inflated to flatten the plaque." - ANSWER - A. In a carotid endarterectomy, the carotid artery is
incised and the plaque is removed. The response beginning, "The diseased portion of the artery
in the brain is replaced" describes an arterial graft procedure. The answer beginning, "A
catheter with a deflated balloon is positioned at the narrow area" describes an angioplasty. The
final response beginning, "A wire is threaded through the artery" describes the mechanical
embolus removal in cerebral ischemia (MERCI) procedure.
A patient admitted with possible stroke has been aphasic for 3 hours and his current blood
pressure (BP) is 174/94 mm Hg. Which order by the health care provider should the nurse
question?
a. Keep head of bed elevated at least 30 degrees.
b. Infuse normal saline intravenously at 75 mL/hr.
c. Administer tissue plasminogen activator (tape) per protocol.
d. Administer a labetalol (Norm dyne) drip to keep BP less than 140/90 mm Hg. - ANSWER - D.
Because elevated BP may be a protective response to maintain cerebral perfusion,
antihypertensive therapy is recommended only if mean arterial pressure (MAP) is >130 mm Hg
or systolic pressure is >220 mm Hg. Fluid intake should be 1500 to 2000 mL daily to maintain
cerebral blood flow. The head of the bed should be elevated to at least 30 degrees, unless the
patient has symptoms of poor tissue perfusion. tape may be administered if the patient meets
the other criteria for tape use.
A 56-year-old patient arrives in the emergency department with hemiparesis and dysarthria
that started 2 hours previously, and health records show a history of several transient ischemic
attacks (TIAs). The nurse anticipates preparing the patient for
a. surgical endarterectomy.
b. transluminal angioplasty.
c. intravenous heparin administration.
d. tissue plasminogen activator (tape) infusion. - ANSWER - D. The patient's history and clinical
manifestations suggest an acute ischemic stroke and a patient who is seen within 4.5 hours of
stroke onset is likely to receive tape (after screening with a CT scan). Heparin administration in
, the emergency phase is not indicated. Emergent carotid transluminal angioplasty or
endarterectomy is not indicated for the patient who is having an acute ischemic stroke.
A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse identifies
the nursing diagnosis of impaired verbal communication. An appropriate nursing intervention
to help the patient communicate is to
a. asks questions that the patient can answer with "yes" or "no."
b. develops a list of words that the patient can read and practice reciting.
c. has the patient practice her facial and tongue exercises with a mirror.
d. prevents embarrassing the patient by answering for her if she does not respond. - ANSWER -
A. Communication will be facilitated and less frustrating to the patient when questions that
require a "yes" or "no" response are used. When the language areas of the brain are injured,
the patient might not be able to read or recite words, which will frustrate the patient without
improving communication. Expressive aphasia is caused by damage to the language areas of the
brain, not by the areas that control the motor aspects of speech. The nurse should allow time
for the patient to respond.
A 72-year-old patient who has a history of a transient ischemic attack (TIA) has an order for
aspirin 160 mg daily. When the nurse is administering medications, the patient says, "I don't
need the aspirin today. I don't have a fever." Which action should the nurse take?
a. Document that the aspirin was refused by the patient.
b. Tell the patient that the aspirin is used to prevent a fever.
c. Explain that the aspirin is ordered to decrease stroke risk.
d. Call the health care provider to clarify the medication order. - ANSWER - C. Aspirin is ordered
to prevent stroke in patients who have experienced TIAs. Documentation of the patient's
refusal to take the medication is an inadequate response by the nurse. There is no need to
clarify the order with the health care provider. The aspirin is not ordered to prevent aches and
pains.
For a patient who had a right hemisphere stroke the nurse establishes a nursing diagnosis of
a. risk for injury related to denial of deficits and impulsiveness.
b. impaired physical mobility related to right-sided hemiplegia.
