Adult Health I Exam 3 2025 – Galen Gabbard
Nursing Concepts & NCLEX Review real exam
A patient has had an ischemic stroke and has been admitted to the medical unit. What action should the
nurse perform to best prevent joint deformities? -answer-Place a pillow in the axilla when there is
limited external rotation.
A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy.
The nurse explains that this procedure will be done for what purpose? -answer-To remove
atherosclerotic plaques blocking cerebral flow
A patient who just suffered a suspected ischemic stroke is brought to the ED by ambulance. On what
should the nurses primary assessment focus? -answer-Cardiac and respiratory status
The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of
a stroke? -answer-Facial droop
The nurse is caring for a patient diagnosed with an ischemic stroke and knows that effective positioning
of the patient is important. Which of the following should be integrated into the patients plan of care? -
answer-The patient should be placed in a prone position for 15 to 30 minutes several times a day.
A patient who suffered an ischemic stroke now has disturbed sensory perception. What principle should
guide the nurses care of this patient? -answer-The patient should be approached on the side where
visual perception is intact.
What should be included in the patients care plan when establishing an exercise program for a patient
affected by a stroke? -answer-Exercise the affected extremities passively four or five times a day.
A female patient is diagnosed with a right-sided stroke. The patient is now experiencing hemianopsia.
How might the nurse help the patient manage her potential sensory and perceptional difficulties? -
answer-Place the patients extremities where she can see them.
The public health nurse is planning a health promotion campaign that reflects current epidemiologic
trends. The nurse should know that hemorrhagic stroke currently accounts for what percentage of total
strokes in the United States? -answer-Risk factors for ischemic stroke
, A community health nurse is giving an educational presentation about stroke and heart disease at the
local senior citizens center. What nonmodifiable risk factor for stroke should the nurse cite? -answer-
Advanced age
After a major ischemic stroke, a possible complication is cerebral edema. Nursing care during the
immediate recovery period from an ischemic stroke should include which of the following? -answer-
Positioning to avoid hypoxia
The nurse is caring for a patient recovering from an ischemic stroke. What intervention best addresses a
potential complication after an ischemic stroke? -answer-Teaching the patient to perform deep
breathing and coughing exercises
A patient with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue
plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the
patients cardiac and neurologic status, the nurse monitors the patient for signs of what complication? -
answer-Bleeding
When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and neurologic
changes is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke of
which the nurse should be aware? -answer-Alteration in level of consciousness (LOC)
A nurse is caring for a patient diagnosed with a hemorrhagic stroke. When creating this patients plan of
care, what goal should be prioritized? -answer-Maintain and improve cerebral tissue perfusion.
The nurse is preparing health education for a patient who is being discharged after hospitalization for a
hemorrhagic stroke. What content should the nurse include in this education? -answer-Take
antihypertensive medication as ordered.
A patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse
caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what? -
answer-Evidence of hemorrhagic stroke
Describe a tonic-clonic seizure and how a patient may look during an episode. -answer-tonic phase -
stiff, rigid muscles (HULK do not touch)
immediate loss of consciousness
clonic - jerking of all extremities (turn to side)
pt may bite tongue, become incontinent, fatigued, acute confusion, and lethargic
What nursing actions are required if the patient has a new onset tonic-clonic seizure? -answer-turn pt
on side during clonic phase
remove any objects that may harm patient
time the seizure (>5 min is an EMERGENCY)
Nursing Concepts & NCLEX Review real exam
A patient has had an ischemic stroke and has been admitted to the medical unit. What action should the
nurse perform to best prevent joint deformities? -answer-Place a pillow in the axilla when there is
limited external rotation.
A patient diagnosed with transient ischemic attacks (TIAs) is scheduled for a carotid endarterectomy.
The nurse explains that this procedure will be done for what purpose? -answer-To remove
atherosclerotic plaques blocking cerebral flow
A patient who just suffered a suspected ischemic stroke is brought to the ED by ambulance. On what
should the nurses primary assessment focus? -answer-Cardiac and respiratory status
The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of
a stroke? -answer-Facial droop
The nurse is caring for a patient diagnosed with an ischemic stroke and knows that effective positioning
of the patient is important. Which of the following should be integrated into the patients plan of care? -
answer-The patient should be placed in a prone position for 15 to 30 minutes several times a day.
A patient who suffered an ischemic stroke now has disturbed sensory perception. What principle should
guide the nurses care of this patient? -answer-The patient should be approached on the side where
visual perception is intact.
What should be included in the patients care plan when establishing an exercise program for a patient
affected by a stroke? -answer-Exercise the affected extremities passively four or five times a day.
A female patient is diagnosed with a right-sided stroke. The patient is now experiencing hemianopsia.
How might the nurse help the patient manage her potential sensory and perceptional difficulties? -
answer-Place the patients extremities where she can see them.
The public health nurse is planning a health promotion campaign that reflects current epidemiologic
trends. The nurse should know that hemorrhagic stroke currently accounts for what percentage of total
strokes in the United States? -answer-Risk factors for ischemic stroke
, A community health nurse is giving an educational presentation about stroke and heart disease at the
local senior citizens center. What nonmodifiable risk factor for stroke should the nurse cite? -answer-
Advanced age
After a major ischemic stroke, a possible complication is cerebral edema. Nursing care during the
immediate recovery period from an ischemic stroke should include which of the following? -answer-
Positioning to avoid hypoxia
The nurse is caring for a patient recovering from an ischemic stroke. What intervention best addresses a
potential complication after an ischemic stroke? -answer-Teaching the patient to perform deep
breathing and coughing exercises
A patient with a new diagnosis of ischemic stroke is deemed to be a candidate for treatment with tissue
plasminogen activator (t-PA) and has been admitted to the ICU. In addition to closely monitoring the
patients cardiac and neurologic status, the nurse monitors the patient for signs of what complication? -
answer-Bleeding
When caring for a patient who had a hemorrhagic stroke, close monitoring of vital signs and neurologic
changes is imperative. What is the earliest sign of deterioration in a patient with a hemorrhagic stroke of
which the nurse should be aware? -answer-Alteration in level of consciousness (LOC)
A nurse is caring for a patient diagnosed with a hemorrhagic stroke. When creating this patients plan of
care, what goal should be prioritized? -answer-Maintain and improve cerebral tissue perfusion.
The nurse is preparing health education for a patient who is being discharged after hospitalization for a
hemorrhagic stroke. What content should the nurse include in this education? -answer-Take
antihypertensive medication as ordered.
A patient is brought by ambulance to the ED after suffering what the family thinks is a stroke. The nurse
caring for this patient is aware that an absolute contraindication for thrombolytic therapy is what? -
answer-Evidence of hemorrhagic stroke
Describe a tonic-clonic seizure and how a patient may look during an episode. -answer-tonic phase -
stiff, rigid muscles (HULK do not touch)
immediate loss of consciousness
clonic - jerking of all extremities (turn to side)
pt may bite tongue, become incontinent, fatigued, acute confusion, and lethargic
What nursing actions are required if the patient has a new onset tonic-clonic seizure? -answer-turn pt
on side during clonic phase
remove any objects that may harm patient
time the seizure (>5 min is an EMERGENCY)
