STROKE NCLEX QUESTIONS AND
CERTIFIED ANSWERS
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). ANSW✅✅B. Following a transient ischemic attack (TIA), patients
typically are started on medications such as aspirin to inhibit platelet function and decrease stroke
risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial
fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.
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. ANSW✅✅C. During the acute period,
the nurse should place objects on the patient's unaffected side. Because there is a visual defect in
the right half of each eye, an eye patch is not appropriate. The patient should be approached from
the left side. The visual deficit may not resolve, although the patient can learn to compensate for the
defect.
A 58-year-old patient with a left-brain stroke suddenly bursts into tears when family members visit.
The nurse should
a. use a calm voice to ask the patient to stop the crying behavior.
b. explain to the family that depression is normal following a stroke.
c. have the family members leave the patient alone for a few minutes.
d. teach the family that emotional outbursts are common after strokes. ANSW✅✅D. Patients who
have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to the
emotional state of the patient. Depression after a stroke is common, but the suddenness of the
patient's outburst suggests that depression is not the major cause of the behavior. The family should
stay with the patient. The crying is not within the patient's control and asking the patient to stop will
lead to embarrassment.
, The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements
related to impaired self-feeding ability for a left-handed patient with left-sided hemiplegia. Which
intervention should be included in the plan of care?
a. Provide a wide variety of food choices.
b. Provide oral care before and after meals.
c. Assist the patient to eat with the right hand.
d. Teach the patient the "chin-tuck" technique. ANSW✅✅C. Because the nursing diagnosis
indicates that the patient's imbalanced nutrition is related to the left-sided hemiplegia, the
appropriate interventions will focus on teaching the patient to use the right hand for self-feeding.
The other interventions are appropriate for patients with other etiologies for the imbalanced
nutrition.
Which stroke risk factor for a 48-year-old male patient in the clinic is most important for the nurse to
address?
a. The patient is 25 pounds above the ideal weight.
b. The patient drinks a glass of red wine with dinner daily.
c. The patient's usual blood pressure (BP) is 170/94 mm Hg.
d. The patient works at a desk and relaxes by watching television. ANSW✅✅C. Hypertension is the
single most important modifiable risk factor. People who drink more than 1 (for women) or 2 (for
men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity
contribute to stroke risk but not as much as hypertension.
A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which
intervention will be included in the care plan?
a. Apply intermittent pneumatic compression stockings.
b. Assist to dangle on edge of bed and assess for dizziness.
c. Encourage patient to cough and deep breathe every 4 hours.
d. Insert an oropharyngeal airway to prevent airway obstruction. ANSW✅✅A. The patient with a
subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further
bleeding and is at risk for venous thromboembolism (VTE). Activities such as coughing and sitting up
that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because
there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.
A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with
an intracerebral hemorrhage. Which information about the patient is most important to
communicate to the health care provider?
a. The patient's speech is difficult to understand.
CERTIFIED ANSWERS
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). ANSW✅✅B. Following a transient ischemic attack (TIA), patients
typically are started on medications such as aspirin to inhibit platelet function and decrease stroke
risk. tPA is used for acute ischemic stroke. Coumadin is usually used for patients with atrial
fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid hemorrhage.
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. ANSW✅✅C. During the acute period,
the nurse should place objects on the patient's unaffected side. Because there is a visual defect in
the right half of each eye, an eye patch is not appropriate. The patient should be approached from
the left side. The visual deficit may not resolve, although the patient can learn to compensate for the
defect.
A 58-year-old patient with a left-brain stroke suddenly bursts into tears when family members visit.
The nurse should
a. use a calm voice to ask the patient to stop the crying behavior.
b. explain to the family that depression is normal following a stroke.
c. have the family members leave the patient alone for a few minutes.
d. teach the family that emotional outbursts are common after strokes. ANSW✅✅D. Patients who
have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to the
emotional state of the patient. Depression after a stroke is common, but the suddenness of the
patient's outburst suggests that depression is not the major cause of the behavior. The family should
stay with the patient. The crying is not within the patient's control and asking the patient to stop will
lead to embarrassment.
, The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements
related to impaired self-feeding ability for a left-handed patient with left-sided hemiplegia. Which
intervention should be included in the plan of care?
a. Provide a wide variety of food choices.
b. Provide oral care before and after meals.
c. Assist the patient to eat with the right hand.
d. Teach the patient the "chin-tuck" technique. ANSW✅✅C. Because the nursing diagnosis
indicates that the patient's imbalanced nutrition is related to the left-sided hemiplegia, the
appropriate interventions will focus on teaching the patient to use the right hand for self-feeding.
The other interventions are appropriate for patients with other etiologies for the imbalanced
nutrition.
Which stroke risk factor for a 48-year-old male patient in the clinic is most important for the nurse to
address?
a. The patient is 25 pounds above the ideal weight.
b. The patient drinks a glass of red wine with dinner daily.
c. The patient's usual blood pressure (BP) is 170/94 mm Hg.
d. The patient works at a desk and relaxes by watching television. ANSW✅✅C. Hypertension is the
single most important modifiable risk factor. People who drink more than 1 (for women) or 2 (for
men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity
contribute to stroke risk but not as much as hypertension.
A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which
intervention will be included in the care plan?
a. Apply intermittent pneumatic compression stockings.
b. Assist to dangle on edge of bed and assess for dizziness.
c. Encourage patient to cough and deep breathe every 4 hours.
d. Insert an oropharyngeal airway to prevent airway obstruction. ANSW✅✅A. The patient with a
subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm or further
bleeding and is at risk for venous thromboembolism (VTE). Activities such as coughing and sitting up
that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because
there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.
A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with
an intracerebral hemorrhage. Which information about the patient is most important to
communicate to the health care provider?
a. The patient's speech is difficult to understand.
