NCLEX STROKE TEST BANK 122 NEWEST EXAM
2024 QUESTIONS AND CORRECT ANSWERS
WITH RATIONALES ALREADI GRADED A+ |
RECOMMENDED BY EXPERTS!!
The nurse is caring for a patient with a history of transient ischemic attacks (TIAs) and moderate carotid
stenosis who has undergone a carotid endarterectomy. Which of the following postoperative findings
would cause the nurse the most concern?
a) Blood pressure (BP): 128/86 mm Hg
b) Neck pain: 3/10 (0 to 10 pain scale)
c) Mild neck edema
d) Difficulty swallowing - ANSWERS -Difficulty swallowing
The patient's inability to swallow without difficulty would cause the nurse the most concern. Difficulty
in swallowing, hoarseness or other signs of cranial nerve dysfunction must be assessed. The nurse
focuses on assessment of the following cranial nerves: facial (VII), vagus (X), spinal accessory (XI), and
hypoglossal (XII). Some edema in the neck after surgery is expected; however, extensive edema and
hematoma formation can obstruct the airway. Emergency airway supplies, including those needed for
a tracheostomy, must be available. The patient's neck pain and mild BP elevation need addressing but
would not cause the nurse the most concern. Hypotension is avoided to prevent cerebral ischemia
and thrombosis. Uncontrolled hypertension may precipitate cerebral hemorrhage, edema,
hemorrhage at the surgical incision, or disruption of the arterial reconstruction.
,An emergency department nurse is interviewing a client with signs of an ischemic stroke that began 2
hours ago. The client reports that she had a cholecystectomy 6 weeks ago and is taking digoxin,
coumadin, and labetelol. This client is not eligible for thrombolytic therapy for which of the following
reasons?
a) She is not within the treatment time window.
b) She had surgery 6 weeks ago.
c) She is taking digoxin.
d) She is taking coumadin. - ANSWERS -She is taking coumadin.
To be eligible for thrombolytic therapy, the client cannot be taking coumadin. Initiation of
thrombolytic therapy must be within 3 hours in clients with ischemic stroke. The client is not eligible
for thrombolytic therapy if she has had surgery within 14 days. Digoxin and labetelol do not prohibit
thrombolytic therapy.
Which disturbance results in loss of half of the visual field?
a) Anisocoria
b) Homonymous hemianopsia
c) Nystagmus
d) Diplopia - ANSWERS -Homonymous hemianopsia
,Homonymous hemianopsia (loss of half of the visual field) may occur from stroke and may be temporary
or permanent. Double vision is documented as diplopia. Nystagmus is ocular bobbing and may be seen
in multiple sclerosis. Anisocoria is unequal pupils.
A client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is
the best nursing action to be taken?
a) Reposition the tray and plate.
b) Perform a vision field assessment.
c) Know this is a normal finding for CVA.
d) Assist the client with feeding. - ANSWERS -Perform a vision field assessment.
The nurse should perform a vision field assessment to evaluate the client forhemianopia. This finding
could indicate damage to the visual area of the brain as a result of evolving CVA. Repositioning the
tray and assisting with feeding would not be the best nursing action until new finding has been
evaluated. Hemianopia can be associated with a CVA but, when presenting as a new finding, should
be evaluated and reported immediately. (less)
A client is hospitalized when they present to the Emergency Department with right-sided weakness.
Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to their
presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic
deficit was what?
a) Cerebral aneurysm
b) Transient ischemic attack
, c) Left-sided stroke
d) Right-sided stroke - ANSWERS -Transient ischemic attack
A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment caused by a
temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour; some continue
for as long as 1 day. When the symptoms terminate, the client resumes his or her presymptomatic state.
The symptoms do not describe a left- or right-sided stroke or a cerebral aneurysm.
Which of the following terms refer to the failure to recognize familiar objects perceived by the senses?
a) Agnosia
b) Perseveration
c) Apraxia
d) Agraphia - ANSWERS -Agnosia
Auditory agnosia is failure to recognize significance of sounds. Agraphia refers to disturbances in writing
intelligible words. Apraxia refers to inability to perform previously learned purposeful motor acts on a
voluntary basis. Perseveration is the continued and automatic repetition of an activity, word, or phrase
that is no longer appropriate.
During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are.
What would be the instructor's best answer?
a) "Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the
degree of blockage, and the availability of collateral circulation."
2024 QUESTIONS AND CORRECT ANSWERS
WITH RATIONALES ALREADI GRADED A+ |
RECOMMENDED BY EXPERTS!!
The nurse is caring for a patient with a history of transient ischemic attacks (TIAs) and moderate carotid
stenosis who has undergone a carotid endarterectomy. Which of the following postoperative findings
would cause the nurse the most concern?
a) Blood pressure (BP): 128/86 mm Hg
b) Neck pain: 3/10 (0 to 10 pain scale)
c) Mild neck edema
d) Difficulty swallowing - ANSWERS -Difficulty swallowing
The patient's inability to swallow without difficulty would cause the nurse the most concern. Difficulty
in swallowing, hoarseness or other signs of cranial nerve dysfunction must be assessed. The nurse
focuses on assessment of the following cranial nerves: facial (VII), vagus (X), spinal accessory (XI), and
hypoglossal (XII). Some edema in the neck after surgery is expected; however, extensive edema and
hematoma formation can obstruct the airway. Emergency airway supplies, including those needed for
a tracheostomy, must be available. The patient's neck pain and mild BP elevation need addressing but
would not cause the nurse the most concern. Hypotension is avoided to prevent cerebral ischemia
and thrombosis. Uncontrolled hypertension may precipitate cerebral hemorrhage, edema,
hemorrhage at the surgical incision, or disruption of the arterial reconstruction.
,An emergency department nurse is interviewing a client with signs of an ischemic stroke that began 2
hours ago. The client reports that she had a cholecystectomy 6 weeks ago and is taking digoxin,
coumadin, and labetelol. This client is not eligible for thrombolytic therapy for which of the following
reasons?
a) She is not within the treatment time window.
b) She had surgery 6 weeks ago.
c) She is taking digoxin.
d) She is taking coumadin. - ANSWERS -She is taking coumadin.
To be eligible for thrombolytic therapy, the client cannot be taking coumadin. Initiation of
thrombolytic therapy must be within 3 hours in clients with ischemic stroke. The client is not eligible
for thrombolytic therapy if she has had surgery within 14 days. Digoxin and labetelol do not prohibit
thrombolytic therapy.
Which disturbance results in loss of half of the visual field?
a) Anisocoria
b) Homonymous hemianopsia
c) Nystagmus
d) Diplopia - ANSWERS -Homonymous hemianopsia
,Homonymous hemianopsia (loss of half of the visual field) may occur from stroke and may be temporary
or permanent. Double vision is documented as diplopia. Nystagmus is ocular bobbing and may be seen
in multiple sclerosis. Anisocoria is unequal pupils.
A client with a cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is
the best nursing action to be taken?
a) Reposition the tray and plate.
b) Perform a vision field assessment.
c) Know this is a normal finding for CVA.
d) Assist the client with feeding. - ANSWERS -Perform a vision field assessment.
The nurse should perform a vision field assessment to evaluate the client forhemianopia. This finding
could indicate damage to the visual area of the brain as a result of evolving CVA. Repositioning the
tray and assisting with feeding would not be the best nursing action until new finding has been
evaluated. Hemianopia can be associated with a CVA but, when presenting as a new finding, should
be evaluated and reported immediately. (less)
A client is hospitalized when they present to the Emergency Department with right-sided weakness.
Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to their
presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic
deficit was what?
a) Cerebral aneurysm
b) Transient ischemic attack
, c) Left-sided stroke
d) Right-sided stroke - ANSWERS -Transient ischemic attack
A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment caused by a
temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour; some continue
for as long as 1 day. When the symptoms terminate, the client resumes his or her presymptomatic state.
The symptoms do not describe a left- or right-sided stroke or a cerebral aneurysm.
Which of the following terms refer to the failure to recognize familiar objects perceived by the senses?
a) Agnosia
b) Perseveration
c) Apraxia
d) Agraphia - ANSWERS -Agnosia
Auditory agnosia is failure to recognize significance of sounds. Agraphia refers to disturbances in writing
intelligible words. Apraxia refers to inability to perform previously learned purposeful motor acts on a
voluntary basis. Perseveration is the continued and automatic repetition of an activity, word, or phrase
that is no longer appropriate.
During a class on stroke, a junior nursing student asks what the clinical manifestations of stroke are.
What would be the instructor's best answer?
a) "Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the
degree of blockage, and the availability of collateral circulation."
