, CHAPTER LIST
UNIT 1: MANAGEMENT OF PATIENTS Chapter 30: Pneumothorax
WITH NEUROLOGIC DISORDERS Chapter 31: Lower Respiratory Tract Pathogens
Chapter 1: Cerebrovascular Accidents: Brain Chapter 32: Obstructive Sleep Apnea
Attack Chapter 33: Oxygen Supplementation
Chapter 2: Structural Abnormalities Chapter 34: Mechanical Ventilatory Support
Chapter 3: Peripheral Neuropathies
Chapter 4: Neurologic Trauma UNIT IV: MANAGEMENT OF PATIENTS
Chapter 5: Central Nervous System Disorders WITH GASTROINTESTINAL
Chapter 6: Seizure Disorders DISORDERS
Chapter 7: Dementia Chapter 35: Peptic Ulcer Disease
UNIT II: MANAGEMENT OF PATIENTS Chapter 36: Liver Disease
WITH CARDIOVASCULAR DISORDERS Chapter 37: Biliary Dysfunction
Chapter 8: Cardiovascular Assessment Chapter 38: Inflammatory Gastrointestinal
Chapter 9: Hypertension Disorders
Chapter 10: Coronary Artery Disease Chapter 39: Anatomic Intestinal Disorders
Chapter 11: Angina/Myocardial Infarction Chapter 40: Gastrointestinal Bleeding
Chapter 12: Adjunct Equipment/Devices UNIT V: MANAGEMENT OF PATIENTS
Chapter 13: Peripheral Vascular Disease WITH GENITOURINARY DISORDERS
Chapter 14: Inflammatory Cardiac Diseases Chapter 41: Urinary Tract Infections
Chapter 15: Congestive Heart Failure Chapter 42: Renal Insufficiency/Failure
Chapter 16: Valvular Disease Chapter 43: Benign Prostatic Hypertrophy
Chapter 17: Cardiomyopathy Chapter 44: Renal Artery Stenosis
Chapter 18: Ectopy and Dysrhythmia Chapter 45: Nephrolithiasis
Emergencies UNIT VI: MANAGEMENT OF PATIENTS
UNIT III: MANAGEMENT OF PATIENTS WITH ENDOCRINE DISORDERS
WITH PULMONARY DISORDERS Chapter 46: Diabetes Mellitus
Chapter 19: Diagnostic Concepts of Chapter 47: Diabetic Emergencies
Oxygenation and Ventilation Chapter 48: Thyroid Disease
Chapter 20: Measures of Oxygenation and Chapter 49: Cushing’s Syndrome
Ventilation Chapter 50: Primary Adrenocortical
Chapter 21: The Chest X-ray Insufficiency (Addison’s Disease) and Adrenal
Chapter 22: Differential Diagnosis of Crisis
Pulmonary Disorders Chapter 51: Pheochromocytoma
Chapter 23: Pulmonary Function Testing Chapter 52: Syndrome of Inappropriate
Chapter 24: Obstructive (Ventilatory) Lung Antidiuretic Hormone
Diseases Chapter 53: Diabetes Insipidus
Chapter 25: Restrictive (Inflammatory) Lung UNIT VII: MANAGEMENT OF PATIENTS
Diseases and Congestive Heat WITH MUSCULOSKELETAL
Failure/Pulmonary Edema DISORDERS
Chapter 26: Pathophysiologically Derived Chapter 54: Arthritis
Therapy for Respiratory Dysfunction Chapter 55: Subluxations and Dislocations
Chapter 27: Pulmonary Hypertension and Chapter 56: Soft Tissue Injury
Pulmonary Vascular Disorders Chapter 57: Fractures
Chapter 28: Chest Wall and Secondary Pleural Chapter 58: Compartment Syndrome
Disorders Chapter 59: Back Pain Syndromes
Chapter 29: Respiratory Failure
,UNIT VIII: MANAGEMENT OF UNIT XII: COMMON PROBLEMS IN
PATIENTS WITH HEMATOLOGIC ACUTE CARE
DISORDERS Chapter 72: Fever
Chapter 60: Anemias Chapter 73: Pain
Chapter 61: Sickle Cell Anemia Chapter 74: Psychosocial Problems in Acute
Chapter 62: Coagulopathies Care
UNIT IX: MANAGEMENT OF PATIENTS Chapter 75: Management of the Patient in
WITH ONCOLOGIC DISEASE Shock
Chapter 63: Leukiemias Chapter 76: Nutritional Considerations
Chapter 64: Lymphoma Chapter 77: Fluid, Electrolyte, and Acid-Base
Chapter 65: Other Common Cancers Imbalances
UNIT X: MANAGEMENT OF PATIENTS Chapter 78: Poisoning and Drug Toxicities
WITH IMMUNOLOGIC DISORDERS Chapter 79: Wound Management
Chapter 66: HIV/AIDS and Opportunistic Chapter 80: Infections
Infections Chapter 81: Chest, Abdominal, and Eye Trauma
Chapter 67: Autoimmune Diseases Chapter 82: Organ Transplants
UNIT XI: MANAGEMENT OF PATIENTS Chapter 83: Burns
WITH MISCELLANEOUS PROBLEMS Chapter 84: Hospital Admission Considerations
Chapter 68: Integumentary Disorders Chapter 85: Managing the Surgical Patient
Chapter 69: Ectopic Pregnancy and Sexually UNIT XIII: HEALTH PROMOTION
Transmitted Infections Chapter 86: Guidelines for Health Promotion
Chapter 70: Eye, Ear, Nose, and Throat and Screening
Disorders Chapter 87: Major Causes of Mortality in the
Chapter 71: Headache United States
Chapter 88: Immunization Recommendations
,UNIT I: MANAGEMENT OF PATIENTS WITH NEUROLOGIC DISORDERS
Chapter 1: Cerebrovascular Accidents: Brain Attack
Scope Note: This chapter covers the rapid clinical differentiation of ischemic versus hemorrhagic
cerebrovascular accidents, NIHSS assessment, acute thrombolytic decision trees (tPA/tenecteplase eligibility
and contraindications), urgent neuroimaging selection, post-thrombolytic monitoring, blood pressure targets,
dysphagia screening, and evidence-based secondary stroke prevention.
Questions (1–25)
1. An 82-year-old male with a history of hypertension and dyslipidemia presents with acute right-sided
hemiparesis and expressive aphasia. Which clinical risk factor in his medical history carries the highest
relative risk for cardioembolic ischemic stroke?
A. Non-valvular atrial fibrillation
B. Asymptomatic carotid artery stenosis
C. Type 2 diabetes mellitus
D. Essential hypertension
2. An Acute Care Nurse Practitioner (ACNP) is evaluating a patient with suspected acute ischemic stroke.
Which baseline standardized tool must be routinely administered to quantify stroke severity, guide
acute treatment decisions, and monitor for early clinical deterioration?
A. Hunt and Hess Scale
B. National Institutes of Health Stroke Scale (NIHSS)
C. Glasgow Coma Scale (GCS)
D. Modified Rankin Scale (mRS)
3. A 68-year-old female presents to the emergency department with sudden onset of left-sided facial
droop and arm weakness. Her daughter states she was "completely normal" when they spoke on the
phone at 0700. The patient arrived at the hospital at 0930. What is the designated "last known well"
time for calculating her eligibility window for intravenous thrombolysis?
A. 0700
B. The time of her arrival in the CT scanner
C. 0930
D. 0815 (estimated midpoint)
4. An ACNP is reviewing the diagnostic workup protocol for a patient presenting with hyperacute stroke
symptoms. Which diagnostic imaging modality must be performed immediately upon arrival to rule out
intracranial hemorrhage before administering intravenous thrombolytics?
A. Diffusion-weighted magnetic resonance imaging (DW-MRI)
, B. Non-contrast computed tomography (NCCT) of the head
C. Transcranial Doppler ultrasonography
D. Contrast-enhanced computed tomography (CT) of the head
5. A 74-year-old male is being evaluated for intravenous tissue plasminogen activator (tPA) for acute
ischemic stroke. Symptoms began 2 hours ago. Which history finding represents an absolute
contraindication to IV tPA administration?
A. Active internal bleeding or acute intracranial hemorrhage
B. Non-compressible arterial puncture 10 days ago
C. Current treatment with aspirin 81 mg daily
D. Ischemic stroke 6 months ago
6. An ACNP is evaluating a patient with acute ischemic stroke who is eligible for IV thrombolysis. The
patient's initial blood pressure is 198/112 mmHg. According to acute stroke guidelines, what is the
required blood pressure threshold that must be achieved before initiating tPA?
A. Blood pressure < 220/120 mmHg
B. Blood pressure < 185/110 mmHg
C. Blood pressure < 160/100 mmHg
D. Blood pressure < 140/90 mmHg
7. Which set of acute monitoring parameters and nursing interventions is required during the first 24
hours following intravenous tPA administration for acute ischemic stroke?
Select all that apply:
A. Maintain blood pressure strictly below 180/105 mmHg.
B. Continuous cardiac telemetry monitoring for atrial fibrillation detection.
C. Avoid antiplatelet or anticoagulant medications for 24 hours post-tPA.
D. Perform neurological assessments and vital sign checks every 15 minutes for the first 2 hours.
E. Insert an indwelling urinary catheter and nasogastric tube immediately post-infusion.
8. A 62-year-old patient with an acute ischemic stroke receives IV tPA. Ninety minutes after the infusion,
the patient develops a sudden severe headache, acute rise in blood pressure, severe nausea, and a 4-
point drop in NIHSS score. Laboratory parameters show: Platelets 210,000/mcL, INR 1.1, aPTT 31 sec.
What is the most likely acute complication and immediate management step?
A. Acute ischemic recurrence; re-administer a second bolus of tPA immediately.
B. Malignant middle cerebral artery infarction; administer IV mannitol and hypertonic saline.
C. Post-thrombolytic hemorrhagic conversion; stop tPA if running, obtain immediate non-contrast head
CT, and prepare cryoprecipitate.
D. Systemic anaphylaxis; administer IV diphenhydramine and methylprednisolone.
9. An ACNP is managing an acute ischemic stroke patient who is NOT eligible for thrombolytic or
endovascular therapy. The patient's blood pressure is 195/105 mmHg, and he is asymptomatic from a
cardiac standpoint. According to clinical practice guidelines, how should his elevated blood pressure be
managed during the first 24 to 48 hours?
A. Allow permissive hypertension unless blood pressure exceeds 220/120 mmHg.
, B. Rapidly lower Mean Arterial Pressure (MAP) by 30% using IV nicardipine infusion.
C. Administer IV sublingual nifedipine to target a systolic blood pressure < 140 mmHg.
D. Initiate aggressive IV labetalol boluses to achieve a blood pressure < 130/80 mmHg.
10. A 71-year-old female is admitted to the neurointensive care unit following a spontaneous left basal
ganglia intracerebral hemorrhage (ICH). Her initial blood pressure is 210/115 mmHg. What is the
guideline-directed blood pressure management target for acute hemorrhagic stroke with SBP between
150 and 220 mmHg?
A. Rapidly lower and maintain systolic blood pressure to a target of 140 mmHg using continuous IV
antihypertensive infusions.
B. Target a Mean Arterial Pressure (MAP) > 130 mmHg.
C. Withhold all blood pressure lowering agents for 72 hours.
D. Maintain systolic blood pressure between 180 and 200 mmHg to preserve penumbral perfusion.
11. An ACNP is ordering post-stroke care for a newly admitted patient with an acute ischemic stroke.
Before initiating any oral medications, food, or fluid intake, which critical bedside assessment must be
completed?
A. Formal bedside or nursing dysphagia screening test
B. Physical therapy gait assessment
C. Bedside formal mini-mental status examination
D. Bedside carotid duplex examination
12. A 65-year-old patient with an acute ischemic stroke is found to have non-valvular atrial fibrillation on
cardiac telemetry. What is the most appropriate secondary stroke prevention anticoagulant strategy
and timing following acute ischemic stroke?
A. Administer dual antiplatelet therapy (aspirin + clopidogrel) indefinitely.
B. Start oral anticoagulation (DOAC or warfarin) typically between 3 to 14 days post-stroke based on
infarct size and bleeding risk.
C. Initiate aspirin 325 mg daily and avoid long-term anticoagulation.
D. Initiate full-dose IV unfractionated heparin bolus immediately upon admission.
13. Which combination of diagnostic studies constitutes the standard secondary prevention workup to
identify the underlying etiology of an acute non-cardioembolic ischemic stroke?
Select all that apply:
A. Carotid duplex ultrasonography or CT angiography of the neck.
B. Lumbar puncture for CSF myelin basic protein.
C. Fasting lipid panel and HbA1c screening.
D. Transthoracic or transesophageal echocardiography.
E. 12-lead electrocardiogram and continuous cardiac rhythm monitoring.
14. Reorder the following stepwise clinical management actions for a patient presenting with acute
ischemic stroke from arrival in the Emergency Department to post-thrombolytic care:
15. Obtain emergency non-contrast head CT to rule out hemorrhage.
16. Perform rapid NIHSS assessment and establish exact last known well time.
, 17. Calculate tPA dose, administer IV bolus followed by 1-hour infusion.
18. Verify blood pressure is < 185/110 mmHg and check point-of-care blood glucose.
19. Transfer to Neuro ICU for q15min neuro checks and strict BP control < 180/105 mmHg.
What is the correct clinical sequence?
A. 1, 2, 3, 4, 5
B. 2, 4, 1, 5, 3
C. 2, 1, 4, 3, 5
D. 4, 2, 1, 3, 5
15. Scenario: A 70-year-old male with hypertension and type 2 diabetes presents 2 hours after sudden
onset of right facial paralysis, right arm weakness (3/5 strength), and slurred speech. Non-contrast
head CT shows no evidence of hemorrhage or acute ischemic changes. Blood glucose is 142 mg/dL, BP
is 172/96 mmHg, INR is 1.0, and platelets are 240,000/mcL. He has no prior surgical or bleeding history.
What is the most appropriate next clinical intervention?
A. Administer aspirin 325 mg orally and discharge home with outpatient neurology follow-up.
B. Start IV heparin infusion without a bolus.
C. Repeat non-contrast head CT in 24 hours before deciding on thrombolysis.
D. Administer IV tissue plasminogen activator (tPA) at 0.9 mg/kg (max 90 mg).
16. Scenario: A 79-year-old female presents with acute acute-onset expressive aphasia and right
hemiplegia. NIHSS score is 16. Last known well was 3.5 hours ago. Her medical history includes a major
ischemic stroke 2 months ago resulting in mild residual left deficit. Her BP is 154/82 mmHg.
Based on clinical guidelines, why is this patient INELIGIBLE for intravenous tPA?
A. Expressive aphasia is an excluded symptom domain.
B. Her NIHSS score is too high (> 15).
C. Her age exceeds 75 years.
D. Previous ischemic stroke within the preceding 3 months is a major exclusion criterion.
17. Which clinical features and diagnostic findings distinguish Ischemic Stroke from Intracerebral
Hemorrhage (ICH) upon initial presentation?
Clinical / Diagnostic Feature Ischemic Stroke Intracerebral Hemorrhage (ICH)
Focal neurological deficit Rapidly progressive deficit, early
corresponding to vascular severe headache,
Onset & Early Progression
territory; consciousness often nausea/vomiting, rapid decline
preserved initially in consciousness
, Clinical / Diagnostic Feature Ischemic Stroke Intracerebral Hemorrhage (ICH)
Hyperdense intra-parenchymal
Hypodensity (may be normal in
Non-Contrast Head CT Finding blood collection immediately
first 6–12 hours)
visible
Permissive up to 220/120
Rapid BP reduction to target
Primary Acute BP Target mmHg (untreated) or < 185/110
SBP 140 mmHg
mmHg (tPA)
What is the primary pathophysiologic mechanism that causes rapid early neurological decline and decreased
level of consciousness in ICH compared to ischemic stroke?
A. Progressive arterial thrombosis in the contralateral hemisphere.
B. Mass effect, rapid hematoma expansion, and acute rise in intracranial pressure.
C. Rapid autoimmune demyelination of cortical axons.
D. Diffuse vasospasm of the circle of Willis.
18. An ACNP is choosing secondary antiplatelet therapy for a patient with a non-cardioembolic minor
ischemic stroke (NIHSS <= 3) who presented within 24 hours of symptom onset. According to current
guidelines, what antiplatelet regimen is recommended for the first 21 to 90 days?
A. Warfarin target INR 2.0–3.0.
B. Monotherapy with aspirin 81 mg daily indefinitely.
C. Dual Antiplatelet Therapy (DAPT) with aspirin plus clopidogrel.
D. Full-dose therapeutic low-molecular-weight heparin.
19. A patient is admitted following an ischemic stroke secondary to 80% symptomatic left internal carotid
artery stenosis. Vascular surgery is consulted. What is the guideline-directed indication and optimal
timing for carotid endarterectomy (CEA)?
A. CEA is contraindicated for symptomatic stenosis > 70%.
B. CEA should be delayed for at least 6 months post-stroke.
C. CEA should be performed within 2 weeks of the index stroke event for symptomatic 70–99% carotid
stenosis.
D. CEA is recommended only for asymptomatic stenosis < 50%.
20. Laboratory data for a 64-year-old male with acute stroke symptoms:
pH 7.41, PaCO2 38 mmHg, PaO2 92 mmHg, Na 139 mEq/L, K 4.1 mEq/L, Creatinine 0.9 mg/dL, Blood
Glucose 38 mg/dL.
The patient presents with confusion, diaphoresis, right-sided weakness, and slurred speech. What is
the primary diagnosis and immediate intervention indicated by these laboratory values?
A. Hypoglycemic stroke mimic; administer 50 mL of 50% Dextrose (D50W) IV immediately and re-
evaluate.
UNIT 1: MANAGEMENT OF PATIENTS Chapter 30: Pneumothorax
WITH NEUROLOGIC DISORDERS Chapter 31: Lower Respiratory Tract Pathogens
Chapter 1: Cerebrovascular Accidents: Brain Chapter 32: Obstructive Sleep Apnea
Attack Chapter 33: Oxygen Supplementation
Chapter 2: Structural Abnormalities Chapter 34: Mechanical Ventilatory Support
Chapter 3: Peripheral Neuropathies
Chapter 4: Neurologic Trauma UNIT IV: MANAGEMENT OF PATIENTS
Chapter 5: Central Nervous System Disorders WITH GASTROINTESTINAL
Chapter 6: Seizure Disorders DISORDERS
Chapter 7: Dementia Chapter 35: Peptic Ulcer Disease
UNIT II: MANAGEMENT OF PATIENTS Chapter 36: Liver Disease
WITH CARDIOVASCULAR DISORDERS Chapter 37: Biliary Dysfunction
Chapter 8: Cardiovascular Assessment Chapter 38: Inflammatory Gastrointestinal
Chapter 9: Hypertension Disorders
Chapter 10: Coronary Artery Disease Chapter 39: Anatomic Intestinal Disorders
Chapter 11: Angina/Myocardial Infarction Chapter 40: Gastrointestinal Bleeding
Chapter 12: Adjunct Equipment/Devices UNIT V: MANAGEMENT OF PATIENTS
Chapter 13: Peripheral Vascular Disease WITH GENITOURINARY DISORDERS
Chapter 14: Inflammatory Cardiac Diseases Chapter 41: Urinary Tract Infections
Chapter 15: Congestive Heart Failure Chapter 42: Renal Insufficiency/Failure
Chapter 16: Valvular Disease Chapter 43: Benign Prostatic Hypertrophy
Chapter 17: Cardiomyopathy Chapter 44: Renal Artery Stenosis
Chapter 18: Ectopy and Dysrhythmia Chapter 45: Nephrolithiasis
Emergencies UNIT VI: MANAGEMENT OF PATIENTS
UNIT III: MANAGEMENT OF PATIENTS WITH ENDOCRINE DISORDERS
WITH PULMONARY DISORDERS Chapter 46: Diabetes Mellitus
Chapter 19: Diagnostic Concepts of Chapter 47: Diabetic Emergencies
Oxygenation and Ventilation Chapter 48: Thyroid Disease
Chapter 20: Measures of Oxygenation and Chapter 49: Cushing’s Syndrome
Ventilation Chapter 50: Primary Adrenocortical
Chapter 21: The Chest X-ray Insufficiency (Addison’s Disease) and Adrenal
Chapter 22: Differential Diagnosis of Crisis
Pulmonary Disorders Chapter 51: Pheochromocytoma
Chapter 23: Pulmonary Function Testing Chapter 52: Syndrome of Inappropriate
Chapter 24: Obstructive (Ventilatory) Lung Antidiuretic Hormone
Diseases Chapter 53: Diabetes Insipidus
Chapter 25: Restrictive (Inflammatory) Lung UNIT VII: MANAGEMENT OF PATIENTS
Diseases and Congestive Heat WITH MUSCULOSKELETAL
Failure/Pulmonary Edema DISORDERS
Chapter 26: Pathophysiologically Derived Chapter 54: Arthritis
Therapy for Respiratory Dysfunction Chapter 55: Subluxations and Dislocations
Chapter 27: Pulmonary Hypertension and Chapter 56: Soft Tissue Injury
Pulmonary Vascular Disorders Chapter 57: Fractures
Chapter 28: Chest Wall and Secondary Pleural Chapter 58: Compartment Syndrome
Disorders Chapter 59: Back Pain Syndromes
Chapter 29: Respiratory Failure
,UNIT VIII: MANAGEMENT OF UNIT XII: COMMON PROBLEMS IN
PATIENTS WITH HEMATOLOGIC ACUTE CARE
DISORDERS Chapter 72: Fever
Chapter 60: Anemias Chapter 73: Pain
Chapter 61: Sickle Cell Anemia Chapter 74: Psychosocial Problems in Acute
Chapter 62: Coagulopathies Care
UNIT IX: MANAGEMENT OF PATIENTS Chapter 75: Management of the Patient in
WITH ONCOLOGIC DISEASE Shock
Chapter 63: Leukiemias Chapter 76: Nutritional Considerations
Chapter 64: Lymphoma Chapter 77: Fluid, Electrolyte, and Acid-Base
Chapter 65: Other Common Cancers Imbalances
UNIT X: MANAGEMENT OF PATIENTS Chapter 78: Poisoning and Drug Toxicities
WITH IMMUNOLOGIC DISORDERS Chapter 79: Wound Management
Chapter 66: HIV/AIDS and Opportunistic Chapter 80: Infections
Infections Chapter 81: Chest, Abdominal, and Eye Trauma
Chapter 67: Autoimmune Diseases Chapter 82: Organ Transplants
UNIT XI: MANAGEMENT OF PATIENTS Chapter 83: Burns
WITH MISCELLANEOUS PROBLEMS Chapter 84: Hospital Admission Considerations
Chapter 68: Integumentary Disorders Chapter 85: Managing the Surgical Patient
Chapter 69: Ectopic Pregnancy and Sexually UNIT XIII: HEALTH PROMOTION
Transmitted Infections Chapter 86: Guidelines for Health Promotion
Chapter 70: Eye, Ear, Nose, and Throat and Screening
Disorders Chapter 87: Major Causes of Mortality in the
Chapter 71: Headache United States
Chapter 88: Immunization Recommendations
,UNIT I: MANAGEMENT OF PATIENTS WITH NEUROLOGIC DISORDERS
Chapter 1: Cerebrovascular Accidents: Brain Attack
Scope Note: This chapter covers the rapid clinical differentiation of ischemic versus hemorrhagic
cerebrovascular accidents, NIHSS assessment, acute thrombolytic decision trees (tPA/tenecteplase eligibility
and contraindications), urgent neuroimaging selection, post-thrombolytic monitoring, blood pressure targets,
dysphagia screening, and evidence-based secondary stroke prevention.
Questions (1–25)
1. An 82-year-old male with a history of hypertension and dyslipidemia presents with acute right-sided
hemiparesis and expressive aphasia. Which clinical risk factor in his medical history carries the highest
relative risk for cardioembolic ischemic stroke?
A. Non-valvular atrial fibrillation
B. Asymptomatic carotid artery stenosis
C. Type 2 diabetes mellitus
D. Essential hypertension
2. An Acute Care Nurse Practitioner (ACNP) is evaluating a patient with suspected acute ischemic stroke.
Which baseline standardized tool must be routinely administered to quantify stroke severity, guide
acute treatment decisions, and monitor for early clinical deterioration?
A. Hunt and Hess Scale
B. National Institutes of Health Stroke Scale (NIHSS)
C. Glasgow Coma Scale (GCS)
D. Modified Rankin Scale (mRS)
3. A 68-year-old female presents to the emergency department with sudden onset of left-sided facial
droop and arm weakness. Her daughter states she was "completely normal" when they spoke on the
phone at 0700. The patient arrived at the hospital at 0930. What is the designated "last known well"
time for calculating her eligibility window for intravenous thrombolysis?
A. 0700
B. The time of her arrival in the CT scanner
C. 0930
D. 0815 (estimated midpoint)
4. An ACNP is reviewing the diagnostic workup protocol for a patient presenting with hyperacute stroke
symptoms. Which diagnostic imaging modality must be performed immediately upon arrival to rule out
intracranial hemorrhage before administering intravenous thrombolytics?
A. Diffusion-weighted magnetic resonance imaging (DW-MRI)
, B. Non-contrast computed tomography (NCCT) of the head
C. Transcranial Doppler ultrasonography
D. Contrast-enhanced computed tomography (CT) of the head
5. A 74-year-old male is being evaluated for intravenous tissue plasminogen activator (tPA) for acute
ischemic stroke. Symptoms began 2 hours ago. Which history finding represents an absolute
contraindication to IV tPA administration?
A. Active internal bleeding or acute intracranial hemorrhage
B. Non-compressible arterial puncture 10 days ago
C. Current treatment with aspirin 81 mg daily
D. Ischemic stroke 6 months ago
6. An ACNP is evaluating a patient with acute ischemic stroke who is eligible for IV thrombolysis. The
patient's initial blood pressure is 198/112 mmHg. According to acute stroke guidelines, what is the
required blood pressure threshold that must be achieved before initiating tPA?
A. Blood pressure < 220/120 mmHg
B. Blood pressure < 185/110 mmHg
C. Blood pressure < 160/100 mmHg
D. Blood pressure < 140/90 mmHg
7. Which set of acute monitoring parameters and nursing interventions is required during the first 24
hours following intravenous tPA administration for acute ischemic stroke?
Select all that apply:
A. Maintain blood pressure strictly below 180/105 mmHg.
B. Continuous cardiac telemetry monitoring for atrial fibrillation detection.
C. Avoid antiplatelet or anticoagulant medications for 24 hours post-tPA.
D. Perform neurological assessments and vital sign checks every 15 minutes for the first 2 hours.
E. Insert an indwelling urinary catheter and nasogastric tube immediately post-infusion.
8. A 62-year-old patient with an acute ischemic stroke receives IV tPA. Ninety minutes after the infusion,
the patient develops a sudden severe headache, acute rise in blood pressure, severe nausea, and a 4-
point drop in NIHSS score. Laboratory parameters show: Platelets 210,000/mcL, INR 1.1, aPTT 31 sec.
What is the most likely acute complication and immediate management step?
A. Acute ischemic recurrence; re-administer a second bolus of tPA immediately.
B. Malignant middle cerebral artery infarction; administer IV mannitol and hypertonic saline.
C. Post-thrombolytic hemorrhagic conversion; stop tPA if running, obtain immediate non-contrast head
CT, and prepare cryoprecipitate.
D. Systemic anaphylaxis; administer IV diphenhydramine and methylprednisolone.
9. An ACNP is managing an acute ischemic stroke patient who is NOT eligible for thrombolytic or
endovascular therapy. The patient's blood pressure is 195/105 mmHg, and he is asymptomatic from a
cardiac standpoint. According to clinical practice guidelines, how should his elevated blood pressure be
managed during the first 24 to 48 hours?
A. Allow permissive hypertension unless blood pressure exceeds 220/120 mmHg.
, B. Rapidly lower Mean Arterial Pressure (MAP) by 30% using IV nicardipine infusion.
C. Administer IV sublingual nifedipine to target a systolic blood pressure < 140 mmHg.
D. Initiate aggressive IV labetalol boluses to achieve a blood pressure < 130/80 mmHg.
10. A 71-year-old female is admitted to the neurointensive care unit following a spontaneous left basal
ganglia intracerebral hemorrhage (ICH). Her initial blood pressure is 210/115 mmHg. What is the
guideline-directed blood pressure management target for acute hemorrhagic stroke with SBP between
150 and 220 mmHg?
A. Rapidly lower and maintain systolic blood pressure to a target of 140 mmHg using continuous IV
antihypertensive infusions.
B. Target a Mean Arterial Pressure (MAP) > 130 mmHg.
C. Withhold all blood pressure lowering agents for 72 hours.
D. Maintain systolic blood pressure between 180 and 200 mmHg to preserve penumbral perfusion.
11. An ACNP is ordering post-stroke care for a newly admitted patient with an acute ischemic stroke.
Before initiating any oral medications, food, or fluid intake, which critical bedside assessment must be
completed?
A. Formal bedside or nursing dysphagia screening test
B. Physical therapy gait assessment
C. Bedside formal mini-mental status examination
D. Bedside carotid duplex examination
12. A 65-year-old patient with an acute ischemic stroke is found to have non-valvular atrial fibrillation on
cardiac telemetry. What is the most appropriate secondary stroke prevention anticoagulant strategy
and timing following acute ischemic stroke?
A. Administer dual antiplatelet therapy (aspirin + clopidogrel) indefinitely.
B. Start oral anticoagulation (DOAC or warfarin) typically between 3 to 14 days post-stroke based on
infarct size and bleeding risk.
C. Initiate aspirin 325 mg daily and avoid long-term anticoagulation.
D. Initiate full-dose IV unfractionated heparin bolus immediately upon admission.
13. Which combination of diagnostic studies constitutes the standard secondary prevention workup to
identify the underlying etiology of an acute non-cardioembolic ischemic stroke?
Select all that apply:
A. Carotid duplex ultrasonography or CT angiography of the neck.
B. Lumbar puncture for CSF myelin basic protein.
C. Fasting lipid panel and HbA1c screening.
D. Transthoracic or transesophageal echocardiography.
E. 12-lead electrocardiogram and continuous cardiac rhythm monitoring.
14. Reorder the following stepwise clinical management actions for a patient presenting with acute
ischemic stroke from arrival in the Emergency Department to post-thrombolytic care:
15. Obtain emergency non-contrast head CT to rule out hemorrhage.
16. Perform rapid NIHSS assessment and establish exact last known well time.
, 17. Calculate tPA dose, administer IV bolus followed by 1-hour infusion.
18. Verify blood pressure is < 185/110 mmHg and check point-of-care blood glucose.
19. Transfer to Neuro ICU for q15min neuro checks and strict BP control < 180/105 mmHg.
What is the correct clinical sequence?
A. 1, 2, 3, 4, 5
B. 2, 4, 1, 5, 3
C. 2, 1, 4, 3, 5
D. 4, 2, 1, 3, 5
15. Scenario: A 70-year-old male with hypertension and type 2 diabetes presents 2 hours after sudden
onset of right facial paralysis, right arm weakness (3/5 strength), and slurred speech. Non-contrast
head CT shows no evidence of hemorrhage or acute ischemic changes. Blood glucose is 142 mg/dL, BP
is 172/96 mmHg, INR is 1.0, and platelets are 240,000/mcL. He has no prior surgical or bleeding history.
What is the most appropriate next clinical intervention?
A. Administer aspirin 325 mg orally and discharge home with outpatient neurology follow-up.
B. Start IV heparin infusion without a bolus.
C. Repeat non-contrast head CT in 24 hours before deciding on thrombolysis.
D. Administer IV tissue plasminogen activator (tPA) at 0.9 mg/kg (max 90 mg).
16. Scenario: A 79-year-old female presents with acute acute-onset expressive aphasia and right
hemiplegia. NIHSS score is 16. Last known well was 3.5 hours ago. Her medical history includes a major
ischemic stroke 2 months ago resulting in mild residual left deficit. Her BP is 154/82 mmHg.
Based on clinical guidelines, why is this patient INELIGIBLE for intravenous tPA?
A. Expressive aphasia is an excluded symptom domain.
B. Her NIHSS score is too high (> 15).
C. Her age exceeds 75 years.
D. Previous ischemic stroke within the preceding 3 months is a major exclusion criterion.
17. Which clinical features and diagnostic findings distinguish Ischemic Stroke from Intracerebral
Hemorrhage (ICH) upon initial presentation?
Clinical / Diagnostic Feature Ischemic Stroke Intracerebral Hemorrhage (ICH)
Focal neurological deficit Rapidly progressive deficit, early
corresponding to vascular severe headache,
Onset & Early Progression
territory; consciousness often nausea/vomiting, rapid decline
preserved initially in consciousness
, Clinical / Diagnostic Feature Ischemic Stroke Intracerebral Hemorrhage (ICH)
Hyperdense intra-parenchymal
Hypodensity (may be normal in
Non-Contrast Head CT Finding blood collection immediately
first 6–12 hours)
visible
Permissive up to 220/120
Rapid BP reduction to target
Primary Acute BP Target mmHg (untreated) or < 185/110
SBP 140 mmHg
mmHg (tPA)
What is the primary pathophysiologic mechanism that causes rapid early neurological decline and decreased
level of consciousness in ICH compared to ischemic stroke?
A. Progressive arterial thrombosis in the contralateral hemisphere.
B. Mass effect, rapid hematoma expansion, and acute rise in intracranial pressure.
C. Rapid autoimmune demyelination of cortical axons.
D. Diffuse vasospasm of the circle of Willis.
18. An ACNP is choosing secondary antiplatelet therapy for a patient with a non-cardioembolic minor
ischemic stroke (NIHSS <= 3) who presented within 24 hours of symptom onset. According to current
guidelines, what antiplatelet regimen is recommended for the first 21 to 90 days?
A. Warfarin target INR 2.0–3.0.
B. Monotherapy with aspirin 81 mg daily indefinitely.
C. Dual Antiplatelet Therapy (DAPT) with aspirin plus clopidogrel.
D. Full-dose therapeutic low-molecular-weight heparin.
19. A patient is admitted following an ischemic stroke secondary to 80% symptomatic left internal carotid
artery stenosis. Vascular surgery is consulted. What is the guideline-directed indication and optimal
timing for carotid endarterectomy (CEA)?
A. CEA is contraindicated for symptomatic stenosis > 70%.
B. CEA should be delayed for at least 6 months post-stroke.
C. CEA should be performed within 2 weeks of the index stroke event for symptomatic 70–99% carotid
stenosis.
D. CEA is recommended only for asymptomatic stenosis < 50%.
20. Laboratory data for a 64-year-old male with acute stroke symptoms:
pH 7.41, PaCO2 38 mmHg, PaO2 92 mmHg, Na 139 mEq/L, K 4.1 mEq/L, Creatinine 0.9 mg/dL, Blood
Glucose 38 mg/dL.
The patient presents with confusion, diaphoresis, right-sided weakness, and slurred speech. What is
the primary diagnosis and immediate intervention indicated by these laboratory values?
A. Hypoglycemic stroke mimic; administer 50 mL of 50% Dextrose (D50W) IV immediately and re-
evaluate.
