N151 FINAL EXAM NCLEX QUESTIONS (No Rationale) WITH
COMPLETE ANSWERS
After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no
residual effects, the nurse anticipates teaching the patient about?
a. cerebral aneurysm clipping.
b. heparin intravenous infusion.
c. oral low-dose aspirin therapy.
d. tissue plasminogen activator (tPA). - ANSWER C
A 68-year-old patient is being admitted with a possible stroke. Which information from
the assessment indicates that the nurse should consult with the health care provider
before giving the prescribed aspirin?
a. The patient has dysphasia.
b. The patient has atrial fibrillation.
c. The patient reports that symptoms began with a severe headache.
d. The patient has a history of brief episodes of right-sided hemiplegia. - ANSWER C
A 73-year-old patient with a stroke experiences facial drooping on the right side and
right-sided arm and leg paralysis. When admitting the patient, which clinical
manifestation will the nurse expect to find?
a. Impulsive behavior
b. Right-sided neglect
c. Hyperactive left-sided tendon reflexes
d. Difficulty comprehending instructions - ANSWER D
,During the change of shift report a nurse is told that a patient has an occluded left
posterior cerebral artery. The nurse will anticipate that the patient may have
a. dysphasia.
b. confusion.
c. visual deficits.
d. poor judgment. - ANSWER C
When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral
atherosclerosis
a. to monitor and record the blood pressure daily.
b. that Plavix will dissolve clots in the cerebral arteries.
c. that Plavix will reduce cerebral artery plaque formation.
d. to call the health care provider if stools are bloody or tarry. - ANSWER D
A patient with carotid atherosclerosis asks the nurse to describe a carotid
endarterectomy. Which response by the nurse is accurate?
a. "The obstructing plaque is surgically removed from an artery in the neck."
b. "The diseased portion of the artery in the brain is replaced with a synthetic graft."
c. "A wire is threaded through an artery in the leg to the clots in the carotid artery and
the clots are removed."
d. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is
inflated to flatten the plaque." - ANSWER A
A patient admitted with possible stroke has been aphasic for 3 hours and his current
blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should
the nurse question?
,a. Keep head of bed elevated at least 30 degrees.
b. Infuse normal saline intravenously at 75 mL/hr.
c. Administer tissue plasminogen activator (tPA) per protocol.
d. Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg. -
ANSWER D
A 56-year-old patient arrives in the emergency department with hemiparesis and
dysarthria that started 2 hours previously, and health records show a history of several
transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for
a. surgical endarterectomy.
b. transluminal angioplasty.
c. intravenous heparin administration.
d. tissue plasminogen activator (tPA) infusion. - ANSWER D
A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse
identifies the nursing diagnosis of impaired verbal communication. An appropriate
nursing intervention to help the patient communicate is to
a. ask questions that the patient can answer with "yes" or "no."
b. develop a list of words that the patient can read and practice reciting.
c. have the patient practice her facial and tongue exercises with a mirror.
d. prevent embarrassing the patient by answering for her if she does not respond. -
ANSWER A
A 72-year-old patient who has a history of a transient ischemic attack (TIA) has an order
for aspirin 160 mg daily. When the nurse is administering medications, the patient says,
"I don't need the aspirin today. I don't have a fever." Which action should the nurse
take?
a. Document that the aspirin was refused by the patient.
, b. Tell the patient that the aspirin is used to prevent a fever.
c. Explain that the aspirin is ordered to decrease stroke risk.
d. Call the health care provider to clarify the medication order. - ANSWER C
For a patient who had a right hemisphere stroke the nurse establishes a nursing
diagnosis of
a. risk for injury related to denial of deficits and impulsiveness.
b. impaired physical mobility related to right-sided hemiplegia.
c. impaired verbal communication related to speech-language deficits.
d. ineffective coping related to depression and distress about disability. - ANSWER A
A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at
home that resolved after 2 hours. The nurse will anticipate teaching the patient about
a. alteplase (tPA).
b. aspirin (Ecotrin).
c. warfarin (Coumadin).
d. nimodipine (Nimotop). - ANSWER B
When caring for a patient with a new right-sided homonymous hemianopsia resulting
from a stroke, which intervention should the nurse include in the plan of care?
a. Apply an eye patch to the right eye.
b. Approach the patient from the right side.
c. Place objects needed on the patient's left side.
d. Teach the patient that the left visual deficit will resolve. - ANSWER C
COMPLETE ANSWERS
After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no
residual effects, the nurse anticipates teaching the patient about?
a. cerebral aneurysm clipping.
b. heparin intravenous infusion.
c. oral low-dose aspirin therapy.
d. tissue plasminogen activator (tPA). - ANSWER C
A 68-year-old patient is being admitted with a possible stroke. Which information from
the assessment indicates that the nurse should consult with the health care provider
before giving the prescribed aspirin?
a. The patient has dysphasia.
b. The patient has atrial fibrillation.
c. The patient reports that symptoms began with a severe headache.
d. The patient has a history of brief episodes of right-sided hemiplegia. - ANSWER C
A 73-year-old patient with a stroke experiences facial drooping on the right side and
right-sided arm and leg paralysis. When admitting the patient, which clinical
manifestation will the nurse expect to find?
a. Impulsive behavior
b. Right-sided neglect
c. Hyperactive left-sided tendon reflexes
d. Difficulty comprehending instructions - ANSWER D
,During the change of shift report a nurse is told that a patient has an occluded left
posterior cerebral artery. The nurse will anticipate that the patient may have
a. dysphasia.
b. confusion.
c. visual deficits.
d. poor judgment. - ANSWER C
When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral
atherosclerosis
a. to monitor and record the blood pressure daily.
b. that Plavix will dissolve clots in the cerebral arteries.
c. that Plavix will reduce cerebral artery plaque formation.
d. to call the health care provider if stools are bloody or tarry. - ANSWER D
A patient with carotid atherosclerosis asks the nurse to describe a carotid
endarterectomy. Which response by the nurse is accurate?
a. "The obstructing plaque is surgically removed from an artery in the neck."
b. "The diseased portion of the artery in the brain is replaced with a synthetic graft."
c. "A wire is threaded through an artery in the leg to the clots in the carotid artery and
the clots are removed."
d. "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is
inflated to flatten the plaque." - ANSWER A
A patient admitted with possible stroke has been aphasic for 3 hours and his current
blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should
the nurse question?
,a. Keep head of bed elevated at least 30 degrees.
b. Infuse normal saline intravenously at 75 mL/hr.
c. Administer tissue plasminogen activator (tPA) per protocol.
d. Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg. -
ANSWER D
A 56-year-old patient arrives in the emergency department with hemiparesis and
dysarthria that started 2 hours previously, and health records show a history of several
transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for
a. surgical endarterectomy.
b. transluminal angioplasty.
c. intravenous heparin administration.
d. tissue plasminogen activator (tPA) infusion. - ANSWER D
A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse
identifies the nursing diagnosis of impaired verbal communication. An appropriate
nursing intervention to help the patient communicate is to
a. ask questions that the patient can answer with "yes" or "no."
b. develop a list of words that the patient can read and practice reciting.
c. have the patient practice her facial and tongue exercises with a mirror.
d. prevent embarrassing the patient by answering for her if she does not respond. -
ANSWER A
A 72-year-old patient who has a history of a transient ischemic attack (TIA) has an order
for aspirin 160 mg daily. When the nurse is administering medications, the patient says,
"I don't need the aspirin today. I don't have a fever." Which action should the nurse
take?
a. Document that the aspirin was refused by the patient.
, b. Tell the patient that the aspirin is used to prevent a fever.
c. Explain that the aspirin is ordered to decrease stroke risk.
d. Call the health care provider to clarify the medication order. - ANSWER C
For a patient who had a right hemisphere stroke the nurse establishes a nursing
diagnosis of
a. risk for injury related to denial of deficits and impulsiveness.
b. impaired physical mobility related to right-sided hemiplegia.
c. impaired verbal communication related to speech-language deficits.
d. ineffective coping related to depression and distress about disability. - ANSWER A
A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at
home that resolved after 2 hours. The nurse will anticipate teaching the patient about
a. alteplase (tPA).
b. aspirin (Ecotrin).
c. warfarin (Coumadin).
d. nimodipine (Nimotop). - ANSWER B
When caring for a patient with a new right-sided homonymous hemianopsia resulting
from a stroke, which intervention should the nurse include in the plan of care?
a. Apply an eye patch to the right eye.
b. Approach the patient from the right side.
c. Place objects needed on the patient's left side.
d. Teach the patient that the left visual deficit will resolve. - ANSWER C
