RNSG 1538 CORE REVIEW ANSWERS AND
QUESTIONS SET A+
✔✔The nurse is caring for a patient diagnosed with an ischemic stroke and knows that
effective positioning of the patient is important. Which of the following should be
integrated into the patient's plan of care?
A) The patient's hip joint should be maintained in a flexed position.
B) The patient should be in a supine position unless ambulating.
C) The patient should be placed in a prone position for 15 to 30 minutes several times a
day.
D) The patient should be placed in a Trendelenburg position two to three times daily to
promote cerebral perfusion. - ✔✔C) the patient should be placed in a prone position for
15 to 30 minutes several times a day.
✔✔A nurse is caring for a patient diagnosed with a hemorrhagic stroke. When creating
this patient's plan of care, what goal should be prioritized?
A) Prevent complications of immobility.
B) Maintain and improve cerebral tissue perfusion.
C) Relieve anxiety and pain.
D) Relieve sensory deprivation. - ✔✔B) maintain and improve cerebral tissue perfusion
✔✔The nurse is preparing health education for a patient who is being discharged after
hospitalization for a hemorrhagic stroke. What content should the nurse include in this
education?
A) Mild, intermittent seizures can be expected.
B) Take ibuprofen for complaints of a serious headache.
C) Take anti-hypertensive medication as ordered.
D) Drowsiness is normal for the first week after discharge. - ✔✔C) take anti-
hypertensive medication as ordered.
✔✔A patient is brought by ambulance to the ED after suffering what the family thinks is
a stroke. The nurse caring for this patient is aware that an absolute contraindication for
thrombolytic therapy is what?
A) Evidence of hemorrhagic stroke
,B) Blood pressure of ≥ 180/110 mm Hg
C) Evidence of stroke evolution
D) Previous thrombolytic therapy within the past 12 months - ✔✔A) Evidence of
hemorrhagic stroke
✔✔When caring for a patient who has had a stroke, a priority is reduction of ICP. What
patient position is most consistent with this goal?
A) Head turned slightly to the right side
B) Elevation of the head of the bed
C) Position changes every 15 minutes while awake
D) Extension of the neck - ✔✔B) Elevation of the head of the bed
✔✔A patient who suffered an ischemic stroke now has disturbed sensory perception.
What principle should guide the nurse's care of this patient?
A) The patient should be approached on the side where visual perception is intact.
B) Attention to the affected side should be minimized in order to decrease anxiety.
C) The patient should avoid turning in the direction of the defective visual field to
minimize shoulder subluxation.
D) The patient should be approached on the opposite side of where the visual
perception is intact to promote recovery. - ✔✔A) The patient should be approached on
the side where visual perception is intact.
✔✔A female patient is diagnosed with a right-sided stroke. The patient is now
experiencing hemianopsia. How might the nurse help the patient manage her potential
sensory and perceptional difficulties?
A) Keep the lighting in the patient's room low.
B) Place the patient's clock on the affected side.
C) Approach the patient on the side where vision is impaired.
D) Place the patient's extremities where she can see them. - ✔✔D) Place the patient's
extremities where she can see them.
✔✔A patient who has experienced an ischemic stroke has been admitted to the medical
unit. The patient's family in adamant that she remain on bed rest to hasten her recovery
and to conserve energy. What principle of care should inform the nurse's response to
the family?
A) The patient should mobilize as soon as she is physically able.
B) To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks.
C) The patient should remain on bed rest until she expresses a desire to mobilize.
D) Lack of mobility will greatly increase the patient's risk of stroke recurrence. - ✔✔A)
The patient should mobilize as soon as she is physically able.
✔✔A patient has recently begun mobilizing during the recovery from an ischemic stroke.
To protect the patient's safety during mobilization, the nurse should perform what
action?
A) Support the patient's full body weight with a waist belt during ambulation.
,B) Have a colleague follow the patient closely with a wheelchair.
C) Avoid mobilizing the patient in the early morning or late evening.
D) Ensure that the patient's family members do not participate in mobilization. - ✔✔B)
Have a colleague follow the patient closely with a wheelchair.
✔✔A nurse in the ICU is providing care for a patient who has been admitted with a
hemorrhagic stroke. The nurse is performing frequent neurologic assessments and
observes that the patient is becoming progressively more drowsy over the course of the
day. What is the nurse's best response to this assessment finding?
A) Report this finding to the physician as an indication of decreased metabolism.
B) Provide more stimulation to the patient and monitor the patient closely.
C) Recognize this as the expected clinical course of a hemorrhagic stroke.
D) Report this to the physician as a possible sign of clinical deterioration. - ✔✔D) Report
this to the physician as possible sign of clinical deterioration.
✔✔As a member of the stroke team, the nurse knows that thrombolytic therapy carries
the potential for benefit and for harm. The nurse should be cognizant of what
contraindications for thrombolytic therapy? Select all that apply.
A) INR above 1.0
B) Recent intracranial pathology
C) Sudden symptom onset
D) Current anticoagulation therapy
E) Symptom onset greater than 3 hours prior to admission - ✔✔B) Recent intracranial
pathology
D) Current anticoagulation therapy
E) Symptom onset greater than 3 hours prior to admission
✔✔What are some contraindications for thrombolytic therapy? - ✔✔-symptom onset
greater than 3 hours before admission
-patient who is anticoagulated (INR above 1.7)
-patient who has recently had any type of intracranial pathology (previous stroke, head
injury, trauma)
✔✔acoustic nueroma - ✔✔unilateral tinnitus and hearing loss with or without vertigo or
balance disturbance (staggering gait), painful sensation on side of face, may grow slow
and considerable size before diagnosed, possible involuntary eye movement
✔✔A patient has been admitted to the neurologic unit for the treatment of a newly
diagnosed brain tumor. The patient has just exhibited seizure activity for the first time.
What is the nurse's priority response to this event?
A) Identify the triggers that precipitated the seizure.
B) Implement precautions to ensure the patient's safety.
C) Teach the patient's family about the relationship between brain tumors and seizure
activity.
, D) Ensure that the patient is housed in a private room. - ✔✔B) Implement precautions to
ensure the patient's safety.
✔✔A patient diagnosed with a pituitary adenoma has arrived on the neurologic unit.
When planning the patient's care, the nurse should be aware that the effects of the
tumor will primarily depend on what variable?
A) Whether the tumor utilizes aerobic or anaerobic respiration
B) The specific hormones secreted by the tumor
C) The patient's pre-existing health status
D) Whether the tumor is primary or the result of metastasis - ✔✔B) The specific
hormones secreted by the tumor
✔✔18 & 19. Intracranial Regulation: Brain Tumor.
Classifications and clinical manifestations. - ✔✔I. Intracerebral Tumors
A. Gliomas—infiltrate any portion of the brain; most common type of brain tumor
1. Astrocytomas (grades I and II)
2. Glioblastoma (astrocytoma grades III and IV)
3. Oligodendroglioma (low and high grades)
4. Ependymoma (grades I to IV)
5. Medulloblastoma
II. Tumors Arising From Supporting Structures
A. Meningiomas
B. Neuromas (acoustic neuroma, schwannoma)
C. Pituitary adenomas
✔✔20 Intracranial Regulation: Brain Tumor. Gerontological Considerations. - ✔✔...The
most frequent tumor types in the older adult are anaplastic astrocytoma, glioblastoma,
and cerebral metastases from other sites. The incidence of primary brain tumors and
the likelihood of malignancy increase with age. Intracranial tumors can produce
personality changes, confusion, speech dysfunction, or disturbances of gait. In older
adult patients, early signs and symptoms of intracranial tumors can be easily overlooked
or incorrectly attributed to cognitive and neurologic changes associated with normal
aging. Neurologic signs and symptoms in the older adult must be carefully evaluated,
because brain metastases occur in patients with a history of prior cancer. Researchers
are investigating patterns of care and clinical outcomes of older adult patients with
primary brain tumors
✔✔A male patient with a metastatic brain tumor is having a generalized seizure and
begins vomiting. What should the nurse do first?
A) Perform oral suctioning.
B) Page the physician.
C) Insert a tongue depressor into the patient's mouth.
D) Turn the patient on his side. - ✔✔D) Turn the patient on his side
QUESTIONS SET A+
✔✔The nurse is caring for a patient diagnosed with an ischemic stroke and knows that
effective positioning of the patient is important. Which of the following should be
integrated into the patient's plan of care?
A) The patient's hip joint should be maintained in a flexed position.
B) The patient should be in a supine position unless ambulating.
C) The patient should be placed in a prone position for 15 to 30 minutes several times a
day.
D) The patient should be placed in a Trendelenburg position two to three times daily to
promote cerebral perfusion. - ✔✔C) the patient should be placed in a prone position for
15 to 30 minutes several times a day.
✔✔A nurse is caring for a patient diagnosed with a hemorrhagic stroke. When creating
this patient's plan of care, what goal should be prioritized?
A) Prevent complications of immobility.
B) Maintain and improve cerebral tissue perfusion.
C) Relieve anxiety and pain.
D) Relieve sensory deprivation. - ✔✔B) maintain and improve cerebral tissue perfusion
✔✔The nurse is preparing health education for a patient who is being discharged after
hospitalization for a hemorrhagic stroke. What content should the nurse include in this
education?
A) Mild, intermittent seizures can be expected.
B) Take ibuprofen for complaints of a serious headache.
C) Take anti-hypertensive medication as ordered.
D) Drowsiness is normal for the first week after discharge. - ✔✔C) take anti-
hypertensive medication as ordered.
✔✔A patient is brought by ambulance to the ED after suffering what the family thinks is
a stroke. The nurse caring for this patient is aware that an absolute contraindication for
thrombolytic therapy is what?
A) Evidence of hemorrhagic stroke
,B) Blood pressure of ≥ 180/110 mm Hg
C) Evidence of stroke evolution
D) Previous thrombolytic therapy within the past 12 months - ✔✔A) Evidence of
hemorrhagic stroke
✔✔When caring for a patient who has had a stroke, a priority is reduction of ICP. What
patient position is most consistent with this goal?
A) Head turned slightly to the right side
B) Elevation of the head of the bed
C) Position changes every 15 minutes while awake
D) Extension of the neck - ✔✔B) Elevation of the head of the bed
✔✔A patient who suffered an ischemic stroke now has disturbed sensory perception.
What principle should guide the nurse's care of this patient?
A) The patient should be approached on the side where visual perception is intact.
B) Attention to the affected side should be minimized in order to decrease anxiety.
C) The patient should avoid turning in the direction of the defective visual field to
minimize shoulder subluxation.
D) The patient should be approached on the opposite side of where the visual
perception is intact to promote recovery. - ✔✔A) The patient should be approached on
the side where visual perception is intact.
✔✔A female patient is diagnosed with a right-sided stroke. The patient is now
experiencing hemianopsia. How might the nurse help the patient manage her potential
sensory and perceptional difficulties?
A) Keep the lighting in the patient's room low.
B) Place the patient's clock on the affected side.
C) Approach the patient on the side where vision is impaired.
D) Place the patient's extremities where she can see them. - ✔✔D) Place the patient's
extremities where she can see them.
✔✔A patient who has experienced an ischemic stroke has been admitted to the medical
unit. The patient's family in adamant that she remain on bed rest to hasten her recovery
and to conserve energy. What principle of care should inform the nurse's response to
the family?
A) The patient should mobilize as soon as she is physically able.
B) To prevent contractures and muscle atrophy, bed rest should not exceed 4 weeks.
C) The patient should remain on bed rest until she expresses a desire to mobilize.
D) Lack of mobility will greatly increase the patient's risk of stroke recurrence. - ✔✔A)
The patient should mobilize as soon as she is physically able.
✔✔A patient has recently begun mobilizing during the recovery from an ischemic stroke.
To protect the patient's safety during mobilization, the nurse should perform what
action?
A) Support the patient's full body weight with a waist belt during ambulation.
,B) Have a colleague follow the patient closely with a wheelchair.
C) Avoid mobilizing the patient in the early morning or late evening.
D) Ensure that the patient's family members do not participate in mobilization. - ✔✔B)
Have a colleague follow the patient closely with a wheelchair.
✔✔A nurse in the ICU is providing care for a patient who has been admitted with a
hemorrhagic stroke. The nurse is performing frequent neurologic assessments and
observes that the patient is becoming progressively more drowsy over the course of the
day. What is the nurse's best response to this assessment finding?
A) Report this finding to the physician as an indication of decreased metabolism.
B) Provide more stimulation to the patient and monitor the patient closely.
C) Recognize this as the expected clinical course of a hemorrhagic stroke.
D) Report this to the physician as a possible sign of clinical deterioration. - ✔✔D) Report
this to the physician as possible sign of clinical deterioration.
✔✔As a member of the stroke team, the nurse knows that thrombolytic therapy carries
the potential for benefit and for harm. The nurse should be cognizant of what
contraindications for thrombolytic therapy? Select all that apply.
A) INR above 1.0
B) Recent intracranial pathology
C) Sudden symptom onset
D) Current anticoagulation therapy
E) Symptom onset greater than 3 hours prior to admission - ✔✔B) Recent intracranial
pathology
D) Current anticoagulation therapy
E) Symptom onset greater than 3 hours prior to admission
✔✔What are some contraindications for thrombolytic therapy? - ✔✔-symptom onset
greater than 3 hours before admission
-patient who is anticoagulated (INR above 1.7)
-patient who has recently had any type of intracranial pathology (previous stroke, head
injury, trauma)
✔✔acoustic nueroma - ✔✔unilateral tinnitus and hearing loss with or without vertigo or
balance disturbance (staggering gait), painful sensation on side of face, may grow slow
and considerable size before diagnosed, possible involuntary eye movement
✔✔A patient has been admitted to the neurologic unit for the treatment of a newly
diagnosed brain tumor. The patient has just exhibited seizure activity for the first time.
What is the nurse's priority response to this event?
A) Identify the triggers that precipitated the seizure.
B) Implement precautions to ensure the patient's safety.
C) Teach the patient's family about the relationship between brain tumors and seizure
activity.
, D) Ensure that the patient is housed in a private room. - ✔✔B) Implement precautions to
ensure the patient's safety.
✔✔A patient diagnosed with a pituitary adenoma has arrived on the neurologic unit.
When planning the patient's care, the nurse should be aware that the effects of the
tumor will primarily depend on what variable?
A) Whether the tumor utilizes aerobic or anaerobic respiration
B) The specific hormones secreted by the tumor
C) The patient's pre-existing health status
D) Whether the tumor is primary or the result of metastasis - ✔✔B) The specific
hormones secreted by the tumor
✔✔18 & 19. Intracranial Regulation: Brain Tumor.
Classifications and clinical manifestations. - ✔✔I. Intracerebral Tumors
A. Gliomas—infiltrate any portion of the brain; most common type of brain tumor
1. Astrocytomas (grades I and II)
2. Glioblastoma (astrocytoma grades III and IV)
3. Oligodendroglioma (low and high grades)
4. Ependymoma (grades I to IV)
5. Medulloblastoma
II. Tumors Arising From Supporting Structures
A. Meningiomas
B. Neuromas (acoustic neuroma, schwannoma)
C. Pituitary adenomas
✔✔20 Intracranial Regulation: Brain Tumor. Gerontological Considerations. - ✔✔...The
most frequent tumor types in the older adult are anaplastic astrocytoma, glioblastoma,
and cerebral metastases from other sites. The incidence of primary brain tumors and
the likelihood of malignancy increase with age. Intracranial tumors can produce
personality changes, confusion, speech dysfunction, or disturbances of gait. In older
adult patients, early signs and symptoms of intracranial tumors can be easily overlooked
or incorrectly attributed to cognitive and neurologic changes associated with normal
aging. Neurologic signs and symptoms in the older adult must be carefully evaluated,
because brain metastases occur in patients with a history of prior cancer. Researchers
are investigating patterns of care and clinical outcomes of older adult patients with
primary brain tumors
✔✔A male patient with a metastatic brain tumor is having a generalized seizure and
begins vomiting. What should the nurse do first?
A) Perform oral suctioning.
B) Page the physician.
C) Insert a tongue depressor into the patient's mouth.
D) Turn the patient on his side. - ✔✔D) Turn the patient on his side
