©THEBRIGHT 2024/2025 ALL RIGHTS RESERVED 10:15AM A+
MedSurg Neurological Disorders Exam
Questions And Answers |Latest 2025 |
Guaranteed Pass.
Regular oral hygiene is an essential intervention for a client who has had a stroke. Which of the
following nursing measures is inappropriate when providing oral hygiene?
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. - Answer✔A.
client should be positioned on the side, not on the back. This lateral position helps secretions
escape from the throat and mouth, minimizing the risk of aspiration.
A 78-year-old client is admitted to the emergency department with numbness and weakness of
the left arm and slurred speech. Which nursing intervention is a priority?
A. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
B. Discuss the precipitating factors that caused the symptoms.
C. Schedule for A STAT computer tomography (CT) scan of the head.
D. Notify the speech pathologist for an emergency consultation. - Answer✔C.
A CT scan will determine if the client is having a stroke or has a brain tumour or another
neurological disorder. This would also determine if it is a hemorrhagic or ischemic accident and
guide the treatment because only an ischemic stroke can use tPA.
A client arrives in the emergency department with an ischemic stroke and receives tissue
plasminogen activator (t-PA) administration. Which is the priority nursing assessment?
1
,©THEBRIGHT 2024/2025 ALL RIGHTS RESERVED 10:15AM A+
A. Time of onset of current stroke
B. Complete physical and history
C. Current medications
D. Upcoming surgical procedures - Answer✔A.
The time of onset of a stroke to t-PA administration is critical. Administration within 3 hours has
better outcomes. Tissue plasminogen activator (tPA) is classified as a serine protease (enzymes
that cleave peptide bonds in proteins). It is thus one of the essential components of the
dissolution of blood clots. Its primary function includes catalyzing the conversion of
plasminogen to plasmin, the primary enzyme involved in dissolving blood clots.
During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to
control the client's:
A. Pulse
B. Respirations
C. Blood pressure
D. Temperature - Answer✔C.
Controlling the blood pressure is critical because an intracerebral hemorrhage is the major
adverse effect of thrombolytic therapy. Blood pressure should be maintained according to the
physician and is specific to the client's ischemic tissue needs and risks of bleeding from
treatment.
What is a priority nursing assessment in the first 24 hours after admission of the client with a
thrombotic stroke?
A. Cholesterol level
B. Pupil size and pupillary response
C. Bowel sounds
D. Echocardiogram - Answer✔B.
It is crucial to monitor the pupil size and pupillary response to indicate changes around the
cranial nerves. Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful
in determining whether the brain stem is intact. Pupil size and equality is determined by a
2
,©THEBRIGHT 2024/2025 ALL RIGHTS RESERVED 10:15AM A+
balance between parasympathetic and sympathetic innervation. Response to light reflects the
combined function of the optic (II) and oculomotor (III) cranial nerves.
What is the expected outcome of thrombolytic drug therapy?
A. Increased vascular permeability
B. Vasoconstriction
C. Dissolved emboli
D. Prevention of hemorrhage - Answer✔C.
Thrombolytic therapy is used to dissolve emboli and reestablish cerebral perfusion.
Thrombolytic treatment is also known as fibrinolytic or thrombolysis, to dissolve dangerous
intravascular clots to prevent ischemic damage by improving blood flow. Thrombosis is a
significant physiological response that limits hemorrhage caused by large or tiny vascular injury.
The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA).
Which medication would the nurse anticipate being ordered for the client on discharge?
A. A thrombolytic medication
B. A beta-blocker medication
C. An anti-hyperuricemic medication
D. An oral anticoagulant medication - Answer✔D.
Thrombi form secondary to atrial fibrillation. Therefore, an anticoagulant would be anticipated
to prevent thrombus formation; and oral (warfarin [Coumadin]) at discharge versus
intravenous. Oral anticoagulation is indicated for patients with atrial fibrillation or other
sources of cardioembolic sources of TIA.
Which client would the nurse identify as being most at risk for experiencing a CVA?
A. A 39-year-old pregnant female.
B. A 67-year-old Caucasian male.
C. An 84-year-old Japanese female.
D. A 55-year-old African American male. - Answer✔D.
3
, ©THEBRIGHT 2024/2025 ALL RIGHTS RESERVED 10:15AM A+
African Americans have twice the rate of CVAs as Caucasians; males are more likely to have
strokes than females except in advanced years. Of all the risk factors, hypertension is the most
common modifiable risk factor for stroke. Hypertension is most prevalent in African-Americans
and also occurs earlier in life.
Which assessment data would indicate to the nurse that the client would be at risk for a
hemorrhagic stroke?
A. A blood glucose level of 480 mg/dl.
B. A right-sided carotid bruit.
C. A blood pressure of 220/120 mmHg.
D. The presence of bronchogenic carcinoma. - Answer✔C.
Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood
vessel in the cranium. Hypertension is the most common cause of hemorrhagic stroke. Long
standing hypertension produces degeneration of media, breakage of the elastic lamina, and
fragmentation of smooth muscles of arteries.
The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided
paralysis. Which action by the UAP requires the nurse to intervene?
A. The assistant places a gait belt around the client's waist prior to ambulating.
B. The assistant places the client on the back with the client's head to the side.
C. The assistant places her hand under the client's right axilla to help him/her move up in bed.
D. The assistant praises the client for attempting to perform ADLs independently. - Answer✔C.
This action is inappropriate and would require intervention by the nurse because pulling on a
flaccid shoulder joint could cause shoulder dislocation; as always use a lift sheet for the client
and nurse safety. Avoid pulling the affected arm. Place a hand behind the scapula when moving
the upper extremity instead of pulling from the arm; Utilize a lift sheet during bed
repositioning. When the patient is sitting provide the arm with a firm support surface
A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe
headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would
be contraindicated in this client in which of the following circumstances?
4
MedSurg Neurological Disorders Exam
Questions And Answers |Latest 2025 |
Guaranteed Pass.
Regular oral hygiene is an essential intervention for a client who has had a stroke. Which of the
following nursing measures is inappropriate when providing oral hygiene?
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. - Answer✔A.
client should be positioned on the side, not on the back. This lateral position helps secretions
escape from the throat and mouth, minimizing the risk of aspiration.
A 78-year-old client is admitted to the emergency department with numbness and weakness of
the left arm and slurred speech. Which nursing intervention is a priority?
A. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
B. Discuss the precipitating factors that caused the symptoms.
C. Schedule for A STAT computer tomography (CT) scan of the head.
D. Notify the speech pathologist for an emergency consultation. - Answer✔C.
A CT scan will determine if the client is having a stroke or has a brain tumour or another
neurological disorder. This would also determine if it is a hemorrhagic or ischemic accident and
guide the treatment because only an ischemic stroke can use tPA.
A client arrives in the emergency department with an ischemic stroke and receives tissue
plasminogen activator (t-PA) administration. Which is the priority nursing assessment?
1
,©THEBRIGHT 2024/2025 ALL RIGHTS RESERVED 10:15AM A+
A. Time of onset of current stroke
B. Complete physical and history
C. Current medications
D. Upcoming surgical procedures - Answer✔A.
The time of onset of a stroke to t-PA administration is critical. Administration within 3 hours has
better outcomes. Tissue plasminogen activator (tPA) is classified as a serine protease (enzymes
that cleave peptide bonds in proteins). It is thus one of the essential components of the
dissolution of blood clots. Its primary function includes catalyzing the conversion of
plasminogen to plasmin, the primary enzyme involved in dissolving blood clots.
During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to
control the client's:
A. Pulse
B. Respirations
C. Blood pressure
D. Temperature - Answer✔C.
Controlling the blood pressure is critical because an intracerebral hemorrhage is the major
adverse effect of thrombolytic therapy. Blood pressure should be maintained according to the
physician and is specific to the client's ischemic tissue needs and risks of bleeding from
treatment.
What is a priority nursing assessment in the first 24 hours after admission of the client with a
thrombotic stroke?
A. Cholesterol level
B. Pupil size and pupillary response
C. Bowel sounds
D. Echocardiogram - Answer✔B.
It is crucial to monitor the pupil size and pupillary response to indicate changes around the
cranial nerves. Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful
in determining whether the brain stem is intact. Pupil size and equality is determined by a
2
,©THEBRIGHT 2024/2025 ALL RIGHTS RESERVED 10:15AM A+
balance between parasympathetic and sympathetic innervation. Response to light reflects the
combined function of the optic (II) and oculomotor (III) cranial nerves.
What is the expected outcome of thrombolytic drug therapy?
A. Increased vascular permeability
B. Vasoconstriction
C. Dissolved emboli
D. Prevention of hemorrhage - Answer✔C.
Thrombolytic therapy is used to dissolve emboli and reestablish cerebral perfusion.
Thrombolytic treatment is also known as fibrinolytic or thrombolysis, to dissolve dangerous
intravascular clots to prevent ischemic damage by improving blood flow. Thrombosis is a
significant physiological response that limits hemorrhage caused by large or tiny vascular injury.
The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA).
Which medication would the nurse anticipate being ordered for the client on discharge?
A. A thrombolytic medication
B. A beta-blocker medication
C. An anti-hyperuricemic medication
D. An oral anticoagulant medication - Answer✔D.
Thrombi form secondary to atrial fibrillation. Therefore, an anticoagulant would be anticipated
to prevent thrombus formation; and oral (warfarin [Coumadin]) at discharge versus
intravenous. Oral anticoagulation is indicated for patients with atrial fibrillation or other
sources of cardioembolic sources of TIA.
Which client would the nurse identify as being most at risk for experiencing a CVA?
A. A 39-year-old pregnant female.
B. A 67-year-old Caucasian male.
C. An 84-year-old Japanese female.
D. A 55-year-old African American male. - Answer✔D.
3
, ©THEBRIGHT 2024/2025 ALL RIGHTS RESERVED 10:15AM A+
African Americans have twice the rate of CVAs as Caucasians; males are more likely to have
strokes than females except in advanced years. Of all the risk factors, hypertension is the most
common modifiable risk factor for stroke. Hypertension is most prevalent in African-Americans
and also occurs earlier in life.
Which assessment data would indicate to the nurse that the client would be at risk for a
hemorrhagic stroke?
A. A blood glucose level of 480 mg/dl.
B. A right-sided carotid bruit.
C. A blood pressure of 220/120 mmHg.
D. The presence of bronchogenic carcinoma. - Answer✔C.
Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a ruptured blood
vessel in the cranium. Hypertension is the most common cause of hemorrhagic stroke. Long
standing hypertension produces degeneration of media, breakage of the elastic lamina, and
fragmentation of smooth muscles of arteries.
The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided
paralysis. Which action by the UAP requires the nurse to intervene?
A. The assistant places a gait belt around the client's waist prior to ambulating.
B. The assistant places the client on the back with the client's head to the side.
C. The assistant places her hand under the client's right axilla to help him/her move up in bed.
D. The assistant praises the client for attempting to perform ADLs independently. - Answer✔C.
This action is inappropriate and would require intervention by the nurse because pulling on a
flaccid shoulder joint could cause shoulder dislocation; as always use a lift sheet for the client
and nurse safety. Avoid pulling the affected arm. Place a hand behind the scapula when moving
the upper extremity instead of pulling from the arm; Utilize a lift sheet during bed
repositioning. When the patient is sitting provide the arm with a firm support surface
A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe
headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would
be contraindicated in this client in which of the following circumstances?
4
