NCLEX MED SURG STROKE AND ANSWERS 2024
VERSION VERIFIED RATIONALE GRADED A+
1st thing you do when you suspect a stroke - ansNon-contrast CT scan (determines hemorrhagic vs
ischemic)
4 major causes of hemorrhagic stroke - ans1)deep hypertensive intracerebral hemorrhages, 2)ruptured
saccular aneurysms, 3)arteriovenous malforma�on,4)spontaneous lobar hemorrhages
A caro�d endarterectomy is being considered as a treatment for a pa�ent who has had several TIAs. The
nurse explains to the pa�ent that this surgery
a. is used to restore blood to the brain following an obstruc�on of a cerebral artery
b. involves intracranial surgery to join a superficial extracranial artery to an intracranial artery
c. involves removing an atherosclero�c plaque in the caro�d artery to prevent an impending stroke
d. is sued to open a stenosis in a caro�d artery with a balloon and stent to restore cerebral circula�on -
ansC: Involves removing an atherosclero�c plaque in the caro�d artery to prevent an impending stroke-
An endarterectomy is a removal of an atherosclero�c plaque, and plaque in the caro�d artery may
impair circula�on enough to cause a stroke. A caro�d endarterectomy is performed to prevent a
cerebrovascular accident (CVA), as are most other surgical procedures. An extacranial-intracranial bypass
involves cranial surgery to bypass a sclero�c intacranial artery. Percutaneous transluminal angioplasty
uses a balloon to compress steno�c areas in the caro�d and vertebrobasilar arteries and o�en includes
inser�ng a stent to hold the artery open.
A diagnosis of a ruptured cerebral aneurysm has been made in a pa�ent with manifesta�ons of a stroke.
The nurse an�cipates that treatment op�ons that would be evaluated for the pa�ent include
a. hyperven�la�on therapy
b. surgical clipping of the aneurysm
c. administra�on of hyperosmo�c agents
d. administra�on of thromboly�c therapy - ansB: Surgical clipping of they aneurysm- Surgical
management with clipping of an aneurysm to decrease re bleeding and vasospasm is an op�on for a
stroke cause by rupture of a cerebral aneurysm. Placement of coils into the lumens of the aneurysm by
intercen�onal radiologists is increasing in popularity. Hyperven�la�on therapy would increase
vasodila�on and the poten�al for hemorrhage. Thromboly�c therapy would be absolutely
contraindicated, and if a vessel is patent, osmo�c diure�cs may leak into �ssue, pulling fluid out of the
vessel and increasing edema.
, NCLEX MED SURG STROKE AND ANSWERS 2024
VERSION VERIFIED RATIONALE GRADED A+
A newly admited pa�ent who has suffered a right sided brain stroke has a nursing diagnosis of disturbed
visual sensory percep�on related to homonymous hemianopsia. Early in the care of the pa�ent, the
nurse should
a. place objects on the right side within the pa�ent's field of vision
b. approach the pa�ent from the le� side to encourage the pa�ent to turn the head
c. place objects on the pa�ent's le� side to assess the pa�ent's ability to compensate
d. patch the affected eye to encourage the pa�ent to turn the head to scan the environment - ansA:
Place objects on the right side within the pa�ent's field of vision- the presence of homonymous
hemianopia in a pa�ent with right-hemisphere brain damage causes a loss of vision in the le� field. Early
in the care of the pa�ent, objects should be placed on the right side of the pa�ent in the field of vision,
and the nurse should approach the pa�ent from the right side. Later in treatment, pa�ents should be
taught to turn the head and scan the environment and should be approached from the affected side to
encourage head turning. Eye patches are used if pa�ents have diplopia (double vision).
A nursing interven�on is indicated for the pa�ent with hemiplegia is
a. the use of a footboard to prevent plantar flexion
b. immobiliza�on of the affected arm against the chest with a sling
c. posi�oning the pa�ent in bed with each joint lower than the joint proximal to it
d. having the pa�ent perform passive ROM of the affected limb with the unaffected limb - ansD: Having
the pa�ent perform passive ROM of the affected limb with the unaffected limb- ac�ve ROM should be
ini�ated on the unaffected side as soon as possible, and passive ROM of the affected side should be
started on the first day. Having the pa�ent ac�vely exercise the unaffected side provides the pa�ent with
ac�ve and passive ROM as needed. Use of footboards is controversial because they s�mulate plantar
flexion. The unaffected arm should be supported, but immobiliza�on may precipitate a painful shoulder-
hand syndrome. The pa�ent should be posi�oned with each joint higher than the joint proximal to it to
prevent dependent edema.
A pa�ent comes to the emergency department immediately a�er experiencing numbness of the face
and an inability to speak, but while the pa�ent awaits examina�on, the symptoms disappear and the
pa�ent request discharge. The nurse stresses that it is important for the pa�ent to be evaluated
primarily because
VERSION VERIFIED RATIONALE GRADED A+
1st thing you do when you suspect a stroke - ansNon-contrast CT scan (determines hemorrhagic vs
ischemic)
4 major causes of hemorrhagic stroke - ans1)deep hypertensive intracerebral hemorrhages, 2)ruptured
saccular aneurysms, 3)arteriovenous malforma�on,4)spontaneous lobar hemorrhages
A caro�d endarterectomy is being considered as a treatment for a pa�ent who has had several TIAs. The
nurse explains to the pa�ent that this surgery
a. is used to restore blood to the brain following an obstruc�on of a cerebral artery
b. involves intracranial surgery to join a superficial extracranial artery to an intracranial artery
c. involves removing an atherosclero�c plaque in the caro�d artery to prevent an impending stroke
d. is sued to open a stenosis in a caro�d artery with a balloon and stent to restore cerebral circula�on -
ansC: Involves removing an atherosclero�c plaque in the caro�d artery to prevent an impending stroke-
An endarterectomy is a removal of an atherosclero�c plaque, and plaque in the caro�d artery may
impair circula�on enough to cause a stroke. A caro�d endarterectomy is performed to prevent a
cerebrovascular accident (CVA), as are most other surgical procedures. An extacranial-intracranial bypass
involves cranial surgery to bypass a sclero�c intacranial artery. Percutaneous transluminal angioplasty
uses a balloon to compress steno�c areas in the caro�d and vertebrobasilar arteries and o�en includes
inser�ng a stent to hold the artery open.
A diagnosis of a ruptured cerebral aneurysm has been made in a pa�ent with manifesta�ons of a stroke.
The nurse an�cipates that treatment op�ons that would be evaluated for the pa�ent include
a. hyperven�la�on therapy
b. surgical clipping of the aneurysm
c. administra�on of hyperosmo�c agents
d. administra�on of thromboly�c therapy - ansB: Surgical clipping of they aneurysm- Surgical
management with clipping of an aneurysm to decrease re bleeding and vasospasm is an op�on for a
stroke cause by rupture of a cerebral aneurysm. Placement of coils into the lumens of the aneurysm by
intercen�onal radiologists is increasing in popularity. Hyperven�la�on therapy would increase
vasodila�on and the poten�al for hemorrhage. Thromboly�c therapy would be absolutely
contraindicated, and if a vessel is patent, osmo�c diure�cs may leak into �ssue, pulling fluid out of the
vessel and increasing edema.
, NCLEX MED SURG STROKE AND ANSWERS 2024
VERSION VERIFIED RATIONALE GRADED A+
A newly admited pa�ent who has suffered a right sided brain stroke has a nursing diagnosis of disturbed
visual sensory percep�on related to homonymous hemianopsia. Early in the care of the pa�ent, the
nurse should
a. place objects on the right side within the pa�ent's field of vision
b. approach the pa�ent from the le� side to encourage the pa�ent to turn the head
c. place objects on the pa�ent's le� side to assess the pa�ent's ability to compensate
d. patch the affected eye to encourage the pa�ent to turn the head to scan the environment - ansA:
Place objects on the right side within the pa�ent's field of vision- the presence of homonymous
hemianopia in a pa�ent with right-hemisphere brain damage causes a loss of vision in the le� field. Early
in the care of the pa�ent, objects should be placed on the right side of the pa�ent in the field of vision,
and the nurse should approach the pa�ent from the right side. Later in treatment, pa�ents should be
taught to turn the head and scan the environment and should be approached from the affected side to
encourage head turning. Eye patches are used if pa�ents have diplopia (double vision).
A nursing interven�on is indicated for the pa�ent with hemiplegia is
a. the use of a footboard to prevent plantar flexion
b. immobiliza�on of the affected arm against the chest with a sling
c. posi�oning the pa�ent in bed with each joint lower than the joint proximal to it
d. having the pa�ent perform passive ROM of the affected limb with the unaffected limb - ansD: Having
the pa�ent perform passive ROM of the affected limb with the unaffected limb- ac�ve ROM should be
ini�ated on the unaffected side as soon as possible, and passive ROM of the affected side should be
started on the first day. Having the pa�ent ac�vely exercise the unaffected side provides the pa�ent with
ac�ve and passive ROM as needed. Use of footboards is controversial because they s�mulate plantar
flexion. The unaffected arm should be supported, but immobiliza�on may precipitate a painful shoulder-
hand syndrome. The pa�ent should be posi�oned with each joint higher than the joint proximal to it to
prevent dependent edema.
A pa�ent comes to the emergency department immediately a�er experiencing numbness of the face
and an inability to speak, but while the pa�ent awaits examina�on, the symptoms disappear and the
pa�ent request discharge. The nurse stresses that it is important for the pa�ent to be evaluated
primarily because
