Regular oral hygiene is an essential intervention for the client
who has had a stroke. Which of the following nursing measures
is inappropriate when providing oral hygiene?
A: Placing client on back with small pillow under the head Answer: A
B: Keeping portable suctioning equipment at the bedside
C: Opening the client's mouth with a padded tongue blade
D: Cleaning the clients mouth and teeth with toothbrush
A 78 year old client is admitted to the ED with numbness and
weakness of the left arm and slurred speech. Which nursing
intervention is priority?
A: Prepare to administer recombinant tissue plasminogen activa-
Answer: C
tor (rt-PA)
B: Discuss the precipitating factors that caused the symptoms
C: Schedule a STAT CT scan of head
D: Notify speech pathologist for emergency consult
A client arrives at the ED with ischemic stroke and receives tis-
sue plasminogen activator (t-PA) administration. Which is priority
nursing assessment?
A: Current medications Answer: C
B: Complete physical and history
C: Time of onset of current stroke
D: Upcoming surgical procedures
During the first 24 hours after thrombolytic therapy for ischemic
stroke, the primary goal is to control the clients:
A: Pulse
Answer: C
B: Respiration
C: BP
D: Temperature
What is a priority nursing assessment in the first 24 hours after
admission of client with a thrombotic stroke?
A: Cholesterol level
Answer: B
B: Pupil size and papillary response
C: Vowel sounds
D: Echo
What is expected outcome of thrombolytic drug therapy?
A: Increased vascular permeability
B: Vasoconstriction Answer: C
C: Dissolved emboli
D: Prevention of hemorrhage
The client diagnosed with A-fib, has experienced a TIA. Which
medication would the nurse anticipate being ordered for the client
on discharge?
A: PO anticoagulant medication Answer: A
B: Beta-blocker medication
C: Anti-hyperuricemic medication
D: Thrombolytic medication
Which client would the nurse identify as being MOST at risk for
experiencing a CVA?
A: 55yr. old African American Male
B: 84yr. old Japanese female Answer: A
C: 67yr. old white male
D: 39yr. old prego female
Which assessment data would indicate to nurse that the client
would be at risk for hemorrhagic stroke?
A: Blood glucose level of 480mg/dL
B: Right sided carotid bruit Answer: C
C: BP of 220/120 mm Hg
D: Presence of bronchogenic carcinoma
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