SCRN STROKE CERTIFICATION FINAL EXAM 2026 -2027
Questions & Answers with Detailed Rationales for All Choices -
Verified Solutions - Graded A+
Pass your Stroke Certified Registered Nurse board examination on your first attempt
with this definitive 2026/2027 SCRN practice test bank. This comprehensive preparation
guide features realistic clinical questions complete with verified solutions and deep
rationales for all multiple-choice options, covering hyperacute care, stroke diagnostics,
neurosurgical interventions, and long-term rehabilitation strategies. It is an
indispensable study tool for neuroscience nurses looking to compress study routines,
master American Stroke Association guidelines, and lock in an A+ grade.
1. A 56-year-old male with a history of hypertension and hyperlipidemia presents
with acute-onset right-sided weakness and expressive aphasia. His last known well
(LKW) was 10 hours ago; he was sleeping when symptoms were noticed upon
awakening. His NIHSS is 12. Non-contrast CT shows no hemorrhage and an
ASPECTS of 9. CTA shows a left M1 occlusion. CT perfusion shows a core volume of
15 mL and a penumbra volume of 85 mL (mismatch ratio > 1.8). Which of the
following is the most appropriate acute management per current AHA/ASA
guidelines?
A) IV alteplase 0.9 mg/kg despite LKW > 4.5 hours, based on perfusion mismatch
B) Mechanical thrombectomy without IV alteplase, based on DAWN/DEFUSE-3 criteria
C) IV alteplase followed by mechanical thrombectomy, as the patient meets EXTEND
criteria
D) Aspirin 325 mg and admission to the stroke unit for medical management only
Correct Answer: B (Rationale: This patient is a wake-up stroke with LKW > 4.5 hours,
which excludes IV tPA unless they meet EXTEND criteria (which require DWI-FLAIR
mismatch, not CTP mismatch). DAWN and DEFUSE-3 trials support thrombectomy for
patients with LKW 6–24 hours, NIHSS ≥ 6, and favorable perfusion profiles (core < 70 mL,
mismatch ratio > 1.8, or clinical-core mismatch). Since the patient has a favorable CTP
profile and an M1 occlusion, mechanical thrombectomy is the standard of care. IV tPA is
not indicated beyond 4.5 hours without DWI-FLAIR mismatch (which is not provided).
Aspirin alone is insufficient for a large vessel occlusion.)
,2. A 62-year-old female with a history of paroxysmal atrial fibrillation on
dabigatran 150 mg twice daily presents with acute-onset left-sided weakness and
neglect. Her LKW was 2 hours ago. Her INR is 1.2, aPTT is 38 seconds, and
creatinine is 1.0 mg/dL. CT shows no hemorrhage. CTA shows a right M2 occlusion.
Which of the following is the most appropriate acute treatment for this patient?
A) IV alteplase 0.9 mg/kg, as dabigatran does not affect INR/aPTT and the patient is
within the 4.5-hour window
B) IV tenecteplase 0.25 mg/kg as a single bolus, as it has a shorter half-life and lower
bleeding risk
C) Idarucizumab 5 g IV followed by IV alteplase, as dabigatran reversal is required before
thrombolysis
D) Mechanical thrombectomy without thrombolytics, as the patient is on a DOAC and
tPA is contraindicated
Correct Answer: D (Rationale: Patients on dabigatran are not eligible for IV thrombolytics
unless reversal is documented. Idarucizumab (C) can reverse dabigatran, but the AHA
guidelines recommend against administering tPA after DOAC reversal unless there is
proof of normalization of coagulation (dilute thrombin time or ecarin clotting time), which
is not available in most EDs. Therefore, mechanical thrombectomy is the preferred
approach if a large vessel occlusion is present. The patient has an M2 occlusion, which is
accessible for thrombectomy in many centers. Option A is incorrect because dabigatran is
a DOAC and tPA is contraindicated despite normal INR/aPTT. Option B is incorrect for the
same reason. Option C is not standard practice without lab confirmation of reversal.)
3. A 48-year-old male presents with acute-onset severe headache, nausea,
vomiting, and photophobia. His blood pressure is 180/110 mmHg. Non-contrast
CT shows a hyperdense left middle cerebral artery sign but no hemorrhage. He has
no focal neurological deficits. His LKW was 1 hour ago. Which of the following
diagnoses is the most likely explanation for his isolated headache without focal
signs, and what is the most appropriate next step?
A) Migraine with aura; administer sumatriptan and observe
B) Acute ischemic stroke with a distal M2 occlusion; proceed with tPA
C) Subarachnoid hemorrhage from a ruptured aneurysm despite negative CT; perform
lumbar puncture
D) Acute hypertensive encephalopathy; lower BP to < 140/90 mmHg
Correct Answer: B (Rationale: A hyperdense MCA sign indicates a thrombus in the MCA.
This patient has an acute ischemic stroke with a proximal or distal occlusion. Focal deficits
may be subtle or absent if the infarct is in a non-eloquent area or if the patient has a
,dominant hemisphere lesion that is not yet causing appreciable deficits. The absence of
focal signs does not exclude stroke. CT is negative for hemorrhage, and the patient is
within 4.5 hours, so tPA is indicated. Option A (migraine) is less likely with a hyperdense
vessel sign. Option C (SAH) would show blood in the subarachnoid space; the hyperdense
MCA sign is not typical for SAH. Option D (hypertensive encephalopathy) would have
global symptoms, not an isolated hyperdense vessel.)
4. A 72-year-old female with a history of hypertension and diabetes presents with
acute-onset left-sided hemiparesis, neglect, and a left homonymous hemianopia.
Her LKW was 6 hours ago. She is on warfarin for a mechanical mitral valve with an
INR of 2.5. CTA shows a right ICA terminus occlusion with good collateral flow. CT
perfusion shows a core volume of 20 mL and a penumbra of 120 mL. Which of the
following is the most appropriate treatment?
A) Reverse warfarin with vitamin K and fresh frozen plasma, then administer IV alteplase
B) Mechanical thrombectomy without reversal of warfarin
C) Administer IV tenecteplase 0.25 mg/kg despite the INR, as mechanical valve is not a
contraindication
D) Administer aspirin and clopidogrel and observe
Correct Answer: B (Rationale: Mechanical thrombectomy can be performed in patients on
warfarin with an INR > 1.7 without reversal, as the procedure is not dependent on
systemic coagulation status. The benefit of thrombectomy in a patient with a large vessel
occlusion, salvageable penumbra, and good collaterals outweighs the bleeding risk. Option
A is incorrect because reversal takes time and may delay thrombectomy. Option C is
incorrect because INR > 1.7 is an absolute contraindication to IV thrombolytics. Option D
is incorrect because a large vessel occlusion requires thrombectomy, not just antiplatelet
therapy.)
5. A 55-year-old male with a history of hypertension and smoking presents with
acute-onset right-sided weakness, dysarthria, and right facial droop. His LKW was
2 hours ago. His BP is 220/120 mmHg. He is given IV labetalol 10 mg, and his BP
drops to 185/100 mmHg. He is a candidate for IV tPA. Which of the following is
the most appropriate next step?
A) Administer IV alteplase 0.9 mg/kg immediately, as BP is now < 185/110
B) Administer another dose of labetalol to lower BP to < 140/90 before tPA
, C) Hold tPA and start aspirin, as the initial BP was too high for tPA
D) Perform CTA before tPA to rule out a large vessel occlusion
Correct Answer: A (Rationale: The BP threshold for tPA is < 185/110 mmHg. Once the BP
is controlled to this level, tPA can be administered. There is no need to lower BP to <
140/90 (B) before tPA. Initial elevated BP (C) is not a contraindication if it can be
controlled. CTA (D) should not delay tPA; it can be done after tPA is started or
concurrently.)
6. A 68-year-old male with a history of coronary artery disease and atrial
fibrillation presents with acute-onset right-sided weakness and aphasia. His LKW
was 4 hours ago. He is on apixaban 5 mg twice daily. His creatinine is 1.0 mg/dL,
and his platelet count is 250,000/µL. CTA shows a left M1 occlusion. Which of the
following is the most appropriate acute treatment?
A) IV alteplase 0.9 mg/kg, as apixaban does not affect INR
B) IV tenecteplase 0.25 mg/kg, as it has a lower bleeding risk
C) Andexanet alfa 800 mg IV bolus followed by IV alteplase
D) Mechanical thrombectomy without thrombolytics
Correct Answer: D (Rationale: Patients on apixaban (a factor Xa inhibitor) are not eligible
for IV thrombolytics unless reversal is confirmed. Andexanet alfa (C) can reverse apixaban,
but its use before tPA is not standard practice without coagulation testing (anti-Xa levels).
The current AHA guidelines recommend mechanical thrombectomy for patients on DOACs
who have a large vessel occlusion, without attempting reversal. Option A and B are
incorrect because tPA is contraindicated in patients on DOACs.)
7. A 62-year-old female with a history of hypertension presents with acute-onset
vertigo, diplopia, dysarthria, and ataxia. Her LKW was 2 hours ago. Her BP is
150/85 mmHg. CT is negative. She is given IV tPA. One hour later, she develops a
severe headache and a BP of 200/110 mmHg. A stat CT shows a right cerebellar
hemorrhage with mass effect and hydrocephalus. Which of the following is the
most appropriate immediate intervention?
A) Administer cryoprecipitate and aminocaproic acid, and consult neurosurgery for
possible ventriculostomy
B) Administer mannitol 1 g/kg IV and transfer to the ICU for medical management
C) Administer hypertonic saline and prepare for immediate surgical evacuation
Questions & Answers with Detailed Rationales for All Choices -
Verified Solutions - Graded A+
Pass your Stroke Certified Registered Nurse board examination on your first attempt
with this definitive 2026/2027 SCRN practice test bank. This comprehensive preparation
guide features realistic clinical questions complete with verified solutions and deep
rationales for all multiple-choice options, covering hyperacute care, stroke diagnostics,
neurosurgical interventions, and long-term rehabilitation strategies. It is an
indispensable study tool for neuroscience nurses looking to compress study routines,
master American Stroke Association guidelines, and lock in an A+ grade.
1. A 56-year-old male with a history of hypertension and hyperlipidemia presents
with acute-onset right-sided weakness and expressive aphasia. His last known well
(LKW) was 10 hours ago; he was sleeping when symptoms were noticed upon
awakening. His NIHSS is 12. Non-contrast CT shows no hemorrhage and an
ASPECTS of 9. CTA shows a left M1 occlusion. CT perfusion shows a core volume of
15 mL and a penumbra volume of 85 mL (mismatch ratio > 1.8). Which of the
following is the most appropriate acute management per current AHA/ASA
guidelines?
A) IV alteplase 0.9 mg/kg despite LKW > 4.5 hours, based on perfusion mismatch
B) Mechanical thrombectomy without IV alteplase, based on DAWN/DEFUSE-3 criteria
C) IV alteplase followed by mechanical thrombectomy, as the patient meets EXTEND
criteria
D) Aspirin 325 mg and admission to the stroke unit for medical management only
Correct Answer: B (Rationale: This patient is a wake-up stroke with LKW > 4.5 hours,
which excludes IV tPA unless they meet EXTEND criteria (which require DWI-FLAIR
mismatch, not CTP mismatch). DAWN and DEFUSE-3 trials support thrombectomy for
patients with LKW 6–24 hours, NIHSS ≥ 6, and favorable perfusion profiles (core < 70 mL,
mismatch ratio > 1.8, or clinical-core mismatch). Since the patient has a favorable CTP
profile and an M1 occlusion, mechanical thrombectomy is the standard of care. IV tPA is
not indicated beyond 4.5 hours without DWI-FLAIR mismatch (which is not provided).
Aspirin alone is insufficient for a large vessel occlusion.)
,2. A 62-year-old female with a history of paroxysmal atrial fibrillation on
dabigatran 150 mg twice daily presents with acute-onset left-sided weakness and
neglect. Her LKW was 2 hours ago. Her INR is 1.2, aPTT is 38 seconds, and
creatinine is 1.0 mg/dL. CT shows no hemorrhage. CTA shows a right M2 occlusion.
Which of the following is the most appropriate acute treatment for this patient?
A) IV alteplase 0.9 mg/kg, as dabigatran does not affect INR/aPTT and the patient is
within the 4.5-hour window
B) IV tenecteplase 0.25 mg/kg as a single bolus, as it has a shorter half-life and lower
bleeding risk
C) Idarucizumab 5 g IV followed by IV alteplase, as dabigatran reversal is required before
thrombolysis
D) Mechanical thrombectomy without thrombolytics, as the patient is on a DOAC and
tPA is contraindicated
Correct Answer: D (Rationale: Patients on dabigatran are not eligible for IV thrombolytics
unless reversal is documented. Idarucizumab (C) can reverse dabigatran, but the AHA
guidelines recommend against administering tPA after DOAC reversal unless there is
proof of normalization of coagulation (dilute thrombin time or ecarin clotting time), which
is not available in most EDs. Therefore, mechanical thrombectomy is the preferred
approach if a large vessel occlusion is present. The patient has an M2 occlusion, which is
accessible for thrombectomy in many centers. Option A is incorrect because dabigatran is
a DOAC and tPA is contraindicated despite normal INR/aPTT. Option B is incorrect for the
same reason. Option C is not standard practice without lab confirmation of reversal.)
3. A 48-year-old male presents with acute-onset severe headache, nausea,
vomiting, and photophobia. His blood pressure is 180/110 mmHg. Non-contrast
CT shows a hyperdense left middle cerebral artery sign but no hemorrhage. He has
no focal neurological deficits. His LKW was 1 hour ago. Which of the following
diagnoses is the most likely explanation for his isolated headache without focal
signs, and what is the most appropriate next step?
A) Migraine with aura; administer sumatriptan and observe
B) Acute ischemic stroke with a distal M2 occlusion; proceed with tPA
C) Subarachnoid hemorrhage from a ruptured aneurysm despite negative CT; perform
lumbar puncture
D) Acute hypertensive encephalopathy; lower BP to < 140/90 mmHg
Correct Answer: B (Rationale: A hyperdense MCA sign indicates a thrombus in the MCA.
This patient has an acute ischemic stroke with a proximal or distal occlusion. Focal deficits
may be subtle or absent if the infarct is in a non-eloquent area or if the patient has a
,dominant hemisphere lesion that is not yet causing appreciable deficits. The absence of
focal signs does not exclude stroke. CT is negative for hemorrhage, and the patient is
within 4.5 hours, so tPA is indicated. Option A (migraine) is less likely with a hyperdense
vessel sign. Option C (SAH) would show blood in the subarachnoid space; the hyperdense
MCA sign is not typical for SAH. Option D (hypertensive encephalopathy) would have
global symptoms, not an isolated hyperdense vessel.)
4. A 72-year-old female with a history of hypertension and diabetes presents with
acute-onset left-sided hemiparesis, neglect, and a left homonymous hemianopia.
Her LKW was 6 hours ago. She is on warfarin for a mechanical mitral valve with an
INR of 2.5. CTA shows a right ICA terminus occlusion with good collateral flow. CT
perfusion shows a core volume of 20 mL and a penumbra of 120 mL. Which of the
following is the most appropriate treatment?
A) Reverse warfarin with vitamin K and fresh frozen plasma, then administer IV alteplase
B) Mechanical thrombectomy without reversal of warfarin
C) Administer IV tenecteplase 0.25 mg/kg despite the INR, as mechanical valve is not a
contraindication
D) Administer aspirin and clopidogrel and observe
Correct Answer: B (Rationale: Mechanical thrombectomy can be performed in patients on
warfarin with an INR > 1.7 without reversal, as the procedure is not dependent on
systemic coagulation status. The benefit of thrombectomy in a patient with a large vessel
occlusion, salvageable penumbra, and good collaterals outweighs the bleeding risk. Option
A is incorrect because reversal takes time and may delay thrombectomy. Option C is
incorrect because INR > 1.7 is an absolute contraindication to IV thrombolytics. Option D
is incorrect because a large vessel occlusion requires thrombectomy, not just antiplatelet
therapy.)
5. A 55-year-old male with a history of hypertension and smoking presents with
acute-onset right-sided weakness, dysarthria, and right facial droop. His LKW was
2 hours ago. His BP is 220/120 mmHg. He is given IV labetalol 10 mg, and his BP
drops to 185/100 mmHg. He is a candidate for IV tPA. Which of the following is
the most appropriate next step?
A) Administer IV alteplase 0.9 mg/kg immediately, as BP is now < 185/110
B) Administer another dose of labetalol to lower BP to < 140/90 before tPA
, C) Hold tPA and start aspirin, as the initial BP was too high for tPA
D) Perform CTA before tPA to rule out a large vessel occlusion
Correct Answer: A (Rationale: The BP threshold for tPA is < 185/110 mmHg. Once the BP
is controlled to this level, tPA can be administered. There is no need to lower BP to <
140/90 (B) before tPA. Initial elevated BP (C) is not a contraindication if it can be
controlled. CTA (D) should not delay tPA; it can be done after tPA is started or
concurrently.)
6. A 68-year-old male with a history of coronary artery disease and atrial
fibrillation presents with acute-onset right-sided weakness and aphasia. His LKW
was 4 hours ago. He is on apixaban 5 mg twice daily. His creatinine is 1.0 mg/dL,
and his platelet count is 250,000/µL. CTA shows a left M1 occlusion. Which of the
following is the most appropriate acute treatment?
A) IV alteplase 0.9 mg/kg, as apixaban does not affect INR
B) IV tenecteplase 0.25 mg/kg, as it has a lower bleeding risk
C) Andexanet alfa 800 mg IV bolus followed by IV alteplase
D) Mechanical thrombectomy without thrombolytics
Correct Answer: D (Rationale: Patients on apixaban (a factor Xa inhibitor) are not eligible
for IV thrombolytics unless reversal is confirmed. Andexanet alfa (C) can reverse apixaban,
but its use before tPA is not standard practice without coagulation testing (anti-Xa levels).
The current AHA guidelines recommend mechanical thrombectomy for patients on DOACs
who have a large vessel occlusion, without attempting reversal. Option A and B are
incorrect because tPA is contraindicated in patients on DOACs.)
7. A 62-year-old female with a history of hypertension presents with acute-onset
vertigo, diplopia, dysarthria, and ataxia. Her LKW was 2 hours ago. Her BP is
150/85 mmHg. CT is negative. She is given IV tPA. One hour later, she develops a
severe headache and a BP of 200/110 mmHg. A stat CT shows a right cerebellar
hemorrhage with mass effect and hydrocephalus. Which of the following is the
most appropriate immediate intervention?
A) Administer cryoprecipitate and aminocaproic acid, and consult neurosurgery for
possible ventriculostomy
B) Administer mannitol 1 g/kg IV and transfer to the ICU for medical management
C) Administer hypertonic saline and prepare for immediate surgical evacuation
