MedSurg Neurological Disorders NCLEX Questions
MedSurg Neurological Disorders NCLEX Questions
Study online at https://quizlet.com/_cvp4ix
1. Regular oral hygiene is an essential A.
intervention for a client who has had client should be positioned on the side, not on the
a stroke. Which of the following nurs- back. This lateral position helps secretions escape
ing measures is inappropriate when from the throat and mouth, minimizing the risk of
providing oral hygiene? aspiration.
A. Placing the client on the back with
a small pillow under the head.
B. Keeping portable suctioning
equipment at the bedside.
C. Opening the client's mouth with a
padded tongue blade.
D. Cleaning the client's mouth and
teeth with a toothbrush.
2. A 78-year-old client is admitted to the C.
emergency department with numb- A CT scan will determine if the client is having a
ness and weakness of the left arm stroke or has a brain tumour or another neurolog-
and slurred speech. Which nursing ical disorder. This would also determine if it is a
intervention is a priority? hemorrhagic or ischemic accident and guide the
treatment because only an ischemic stroke can use
A. Prepare to administer recombi- tPA.
nant tissue plasminogen activator
(rt-PA).
B. Discuss the precipitating factors
that caused the symptoms.
C. Schedule for A STAT computer to-
mography (CT) scan of the head.
D. Notify the speech pathologist for
an emergency consultation.
3.
actualstudy Page 1
, MedSurg Neurological Disorders NCLEX Questions
MedSurg Neurological Disorders NCLEX Questions
Study online at https://quizlet.com/_cvp4ix
A client arrives in the emergency A.
department with an ischemic stroke The time of onset of a stroke to t-PA administration
and receives tissue plasminogen ac- is critical. Administration within 3 hours has bet-
tivator (t-PA) administration. Which is ter outcomes. Tissue plasminogen activator (tPA) is
the priority nursing assessment? classified as a serine protease (enzymes that cleave
peptide bonds in proteins). It is thus one of the
A. Time of onset of current stroke essential components of the dissolution of blood
B. Complete physical and history clots. Its primary function includes catalyzing the
C. Current medications conversion of plasminogen to plasmin, the primary
D. Upcoming surgical procedures enzyme involved in dissolving blood clots.
4. During the first 24 hours after throm- C.
bolytic therapy for ischemic stroke, Controlling the blood pressure is critical because an
the primary goal is to control the intracerebral hemorrhage is the major adverse ef-
client's: fect of thrombolytic therapy. Blood pressure should
be maintained according to the physician and is
A. Pulse specific to the client's ischemic tissue needs and
B. Respirations risks of bleeding from treatment.
C. Blood pressure
D. Temperature
5. What is a priority nursing assess- B.
ment in the first 24 hours after ad- It is crucial to monitor the pupil size and pupillary
response to indicate changes around the cranial
mission of the client with a thrombot-
ic stroke? nerves. Pupil reactions are regulated by the ocu-
lomotor (III) cranial nerve and are useful in deter-
A. Cholesterol level mining whether the brain stem is intact. Pupil size
B. Pupil size and pupillary response and equality is determined by a balance between
C. Bowel sounds parasympathetic and sympathetic innervation. Re-
D. Echocardiogram sponse to light reflects the combined function of the
optic (II) and oculomotor (III) cranial nerves.
6.
actualstudy Page 2
, MedSurg Neurological Disorders NCLEX Questions
MedSurg Neurological Disorders NCLEX Questions
Study online at https://quizlet.com/_cvp4ix
What is the expected outcome of C.
thrombolytic drug therapy? Thrombolytic therapy is used to dissolve emboli and
reestablish cerebral perfusion. Thrombolytic treat-
A. Increased vascular permeability ment is also known as fibrinolytic or thrombolysis,
B. Vasoconstriction to dissolve dangerous intravascular clots to prevent
C. Dissolved emboli ischemic damage by improving blood flow. Throm-
D. Prevention of hemorrhage bosis is a significant physiological response that
limits hemorrhage caused by large or tiny vascular
injury.
7. The client diagnosed with atrial fib- D.
rillation has experienced a transient Thrombi form secondary to atrial fibrillation. There-
ischemic attack (TIA). Which medica- fore, an anticoagulant would be anticipated to
tion would the nurse anticipate being prevent thrombus formation; and oral (warfarin
ordered for the client on discharge? [Coumadin]) at discharge versus intravenous. Oral
anticoagulation is indicated for patients with atri-
A. A thrombolytic medication al fibrillation or other sources of cardioembolic
B. A beta-blocker medication sources of TIA.
C. An anti-hyperuricemic medication
D. An oral anticoagulant medication
8. Which client would the nurse identify D.
as being most at risk for experiencing African Americans have twice the rate of CVAs as
a CVA? Caucasians; males are more likely to have strokes
than females except in advanced years. Of all the
A. A 39-year-old pregnant female. risk factors, hypertension is the most common mod-
B. A 67-year-old Caucasian male. ifiable risk factor for stroke. Hypertension is most
C. An 84-year-old Japanese female. prevalent in African-Americans and also occurs ear-
D. A 55-year-old African American lier in life.
male.
9. Which assessment data would in- C.
dicate to the nurse that the client Uncontrolled hypertension is a risk factor for he-
actualstudy Page 3
, MedSurg Neurological Disorders NCLEX Questions
MedSurg Neurological Disorders NCLEX Questions
Study online at https://quizlet.com/_cvp4ix
would be at risk for a hemorrhagic morrhagic stroke, which is a ruptured blood vessel
stroke? in the cranium. Hypertension is the most common
cause of hemorrhagic stroke. Long standing hyper-
A. A blood glucose level of 480 tension produces degeneration of media, breakage
mg/dl. of the elastic lamina, and fragmentation of smooth
B. A right-sided carotid bruit. muscles of arteries.
C. A blood pressure of 220/120
mmHg.
D. The presence of bronchogenic car-
cinoma.
10. The nurse and unlicensed assis- C.
tive personnel (UAP) are caring for This action is inappropriate and would require in-
a client with right-sided paralysis. tervention by the nurse because pulling on a flaccid
Which action by the UAP requires the shoulder joint could cause shoulder dislocation; as
nurse to intervene? always use a lift sheet for the client and nurse safety.
Avoid pulling the affected arm. Place a hand behind
A. The assistant places a gait belt the scapula when moving the upper extremity in-
around the client's waist prior to am- stead of pulling from the arm; Utilize a lift sheet dur-
bulating. ing bed repositioning. When the patient is sitting
B. The assistant places the client on provide the arm with a firm support surface
the back with the client's head to the
side.
C. The assistant places her hand un-
der the client's right axilla to help
him/her move up in bed.
D. The assistant praises the client
for attempting to perform ADLs inde-
pendently.
11. A client admitted to the hospital B.
with a subarachnoid hemorrhage Sudden removal of CSF results in pressures lower in
actualstudy Page 4
MedSurg Neurological Disorders NCLEX Questions
Study online at https://quizlet.com/_cvp4ix
1. Regular oral hygiene is an essential A.
intervention for a client who has had client should be positioned on the side, not on the
a stroke. Which of the following nurs- back. This lateral position helps secretions escape
ing measures is inappropriate when from the throat and mouth, minimizing the risk of
providing oral hygiene? aspiration.
A. Placing the client on the back with
a small pillow under the head.
B. Keeping portable suctioning
equipment at the bedside.
C. Opening the client's mouth with a
padded tongue blade.
D. Cleaning the client's mouth and
teeth with a toothbrush.
2. A 78-year-old client is admitted to the C.
emergency department with numb- A CT scan will determine if the client is having a
ness and weakness of the left arm stroke or has a brain tumour or another neurolog-
and slurred speech. Which nursing ical disorder. This would also determine if it is a
intervention is a priority? hemorrhagic or ischemic accident and guide the
treatment because only an ischemic stroke can use
A. Prepare to administer recombi- tPA.
nant tissue plasminogen activator
(rt-PA).
B. Discuss the precipitating factors
that caused the symptoms.
C. Schedule for A STAT computer to-
mography (CT) scan of the head.
D. Notify the speech pathologist for
an emergency consultation.
3.
actualstudy Page 1
, MedSurg Neurological Disorders NCLEX Questions
MedSurg Neurological Disorders NCLEX Questions
Study online at https://quizlet.com/_cvp4ix
A client arrives in the emergency A.
department with an ischemic stroke The time of onset of a stroke to t-PA administration
and receives tissue plasminogen ac- is critical. Administration within 3 hours has bet-
tivator (t-PA) administration. Which is ter outcomes. Tissue plasminogen activator (tPA) is
the priority nursing assessment? classified as a serine protease (enzymes that cleave
peptide bonds in proteins). It is thus one of the
A. Time of onset of current stroke essential components of the dissolution of blood
B. Complete physical and history clots. Its primary function includes catalyzing the
C. Current medications conversion of plasminogen to plasmin, the primary
D. Upcoming surgical procedures enzyme involved in dissolving blood clots.
4. During the first 24 hours after throm- C.
bolytic therapy for ischemic stroke, Controlling the blood pressure is critical because an
the primary goal is to control the intracerebral hemorrhage is the major adverse ef-
client's: fect of thrombolytic therapy. Blood pressure should
be maintained according to the physician and is
A. Pulse specific to the client's ischemic tissue needs and
B. Respirations risks of bleeding from treatment.
C. Blood pressure
D. Temperature
5. What is a priority nursing assess- B.
ment in the first 24 hours after ad- It is crucial to monitor the pupil size and pupillary
response to indicate changes around the cranial
mission of the client with a thrombot-
ic stroke? nerves. Pupil reactions are regulated by the ocu-
lomotor (III) cranial nerve and are useful in deter-
A. Cholesterol level mining whether the brain stem is intact. Pupil size
B. Pupil size and pupillary response and equality is determined by a balance between
C. Bowel sounds parasympathetic and sympathetic innervation. Re-
D. Echocardiogram sponse to light reflects the combined function of the
optic (II) and oculomotor (III) cranial nerves.
6.
actualstudy Page 2
, MedSurg Neurological Disorders NCLEX Questions
MedSurg Neurological Disorders NCLEX Questions
Study online at https://quizlet.com/_cvp4ix
What is the expected outcome of C.
thrombolytic drug therapy? Thrombolytic therapy is used to dissolve emboli and
reestablish cerebral perfusion. Thrombolytic treat-
A. Increased vascular permeability ment is also known as fibrinolytic or thrombolysis,
B. Vasoconstriction to dissolve dangerous intravascular clots to prevent
C. Dissolved emboli ischemic damage by improving blood flow. Throm-
D. Prevention of hemorrhage bosis is a significant physiological response that
limits hemorrhage caused by large or tiny vascular
injury.
7. The client diagnosed with atrial fib- D.
rillation has experienced a transient Thrombi form secondary to atrial fibrillation. There-
ischemic attack (TIA). Which medica- fore, an anticoagulant would be anticipated to
tion would the nurse anticipate being prevent thrombus formation; and oral (warfarin
ordered for the client on discharge? [Coumadin]) at discharge versus intravenous. Oral
anticoagulation is indicated for patients with atri-
A. A thrombolytic medication al fibrillation or other sources of cardioembolic
B. A beta-blocker medication sources of TIA.
C. An anti-hyperuricemic medication
D. An oral anticoagulant medication
8. Which client would the nurse identify D.
as being most at risk for experiencing African Americans have twice the rate of CVAs as
a CVA? Caucasians; males are more likely to have strokes
than females except in advanced years. Of all the
A. A 39-year-old pregnant female. risk factors, hypertension is the most common mod-
B. A 67-year-old Caucasian male. ifiable risk factor for stroke. Hypertension is most
C. An 84-year-old Japanese female. prevalent in African-Americans and also occurs ear-
D. A 55-year-old African American lier in life.
male.
9. Which assessment data would in- C.
dicate to the nurse that the client Uncontrolled hypertension is a risk factor for he-
actualstudy Page 3
, MedSurg Neurological Disorders NCLEX Questions
MedSurg Neurological Disorders NCLEX Questions
Study online at https://quizlet.com/_cvp4ix
would be at risk for a hemorrhagic morrhagic stroke, which is a ruptured blood vessel
stroke? in the cranium. Hypertension is the most common
cause of hemorrhagic stroke. Long standing hyper-
A. A blood glucose level of 480 tension produces degeneration of media, breakage
mg/dl. of the elastic lamina, and fragmentation of smooth
B. A right-sided carotid bruit. muscles of arteries.
C. A blood pressure of 220/120
mmHg.
D. The presence of bronchogenic car-
cinoma.
10. The nurse and unlicensed assis- C.
tive personnel (UAP) are caring for This action is inappropriate and would require in-
a client with right-sided paralysis. tervention by the nurse because pulling on a flaccid
Which action by the UAP requires the shoulder joint could cause shoulder dislocation; as
nurse to intervene? always use a lift sheet for the client and nurse safety.
Avoid pulling the affected arm. Place a hand behind
A. The assistant places a gait belt the scapula when moving the upper extremity in-
around the client's waist prior to am- stead of pulling from the arm; Utilize a lift sheet dur-
bulating. ing bed repositioning. When the patient is sitting
B. The assistant places the client on provide the arm with a firm support surface
the back with the client's head to the
side.
C. The assistant places her hand un-
der the client's right axilla to help
him/her move up in bed.
D. The assistant praises the client
for attempting to perform ADLs inde-
pendently.
11. A client admitted to the hospital B.
with a subarachnoid hemorrhage Sudden removal of CSF results in pressures lower in
actualstudy Page 4
