Lewis Chapter 57_ Stroke 2/5/2026
1st thing you do when you suspect a stroke Non-contrast CT scan (determines hemorrhagic vs ischemic)
4 major causes of hemorrhagic stroke 1)deep hypertensive intracerebral hemorrhages, 2)ruptured saccular aneurysms,
3)arteriovenous malformation,4)spontaneous lobar hemorrhages
A 40-year-old patient has a ruptured cerebral aneurysm and ANS: A
subarachnoid hemorrhage. Which intervention will be included The patient with a subarachnoid hemorrhage usually has minimal activity to prevent
in the care plan? cerebral vasospasm or further bleeding and is at risk for venous thromboembolism (VTE).
a. Activities such as coughing and sitting up that might increase intracranial pressure (ICP) or
Apply intermittent pneumatic compression stockings. decrease cerebral blood flow are avoided. Because there is no indication that the patient is
b. unconscious, an oropharyngeal airway is inappropriate.
Assist to dangle on edge of bed and assess for dizziness.
c. DIF: Cognitive Level: Apply (application) REF: 1405
Encourage patient to cough and deep breathe every 4 hours. TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
d.
Insert an oropharyngeal airway to prevent airway obstruction.
Lewis Chapter 57_ Stroke Page 1 of 38
,Lewis Chapter 57_ Stroke 2/5/2026
A 47-year-old patient will attempt oral feedings for the first time ANS: C
since having a stroke. The nurse should assess the gag reflex and The patient should be as upright as possible before attempting feeding to make swallowing
then easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially
a. offer water or ice to the patient. Pureed diets are not recommended because the texture is
order a varied pureed diet. too smooth. The patient may have a poor appetite, but the oral feeding should be attempted
b. regardless.
assess the patient's appetite.
c. DIF: Cognitive Level: Apply (application) REF: 1406
assist the patient into a chair. TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
d.
offer the patient a sip of juice.
A 56-year-old patient arrives in the emergency department with ANS: D
hemiparesis and dysarthria that started 2 hours previously, and The patient's history and clinical manifestations suggest an acute ischemic stroke and a
health records show a history of several transient ischemic patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening
attacks (TIAs). The nurse anticipates preparing the patient for with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent
a. carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is
surgical endarterectomy. having an acute ischemic stroke.
b.
transluminal angioplasty. DIF: Cognitive Level: Apply (application) REF: 1391 | 1398
c. TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
intravenous heparin administration.
d.
tissue plasminogen activator (tPA) infusion.
Lewis Chapter 57_ Stroke Page 2 of 38
,Lewis Chapter 57_ Stroke 2/5/2026
A 58-year-old patient with a left-brain stroke suddenly bursts ANS: D
into tears when family members visit. The nurse should Patients who have left-sided brain stroke are prone to emotional outbursts that are not
a. necessarily related to the emotional state of the patient. Depression after a stroke is
use a calm voice to ask the patient to stop the crying behavior. common, but the suddenness of the patient's outburst suggests that depression is not the
b. major cause of the behavior. The family should stay with the patient. The crying is not
explain to the family that depression is normal following a within the patient's control and asking the patient to stop will lead to embarrassment.
stroke.
c. DIF: Cognitive Level: Apply (application) REF: 1409
have the family members leave the patient alone for a few TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
minutes.
d.
teach the family that emotional outbursts are common after
strokes.
A 63-year-old patient who began experiencing right arm and leg ANS:
weakness is admitted to the emergency department. In which C, D, A, B
order will the nurse implement these actions included in the The initial actions should be those that help with airway, breathing, and circulation. Baseline
stroke protocol? (Put a comma and a space between each answer neurologic assessments should be done next. A CT scan will be needed to rule out
choice [A, B, C, D].) hemorrhagic stroke before tPA can be administered.
a. Obtain computed tomography (CT) scan without contrast.
b. Infuse tissue plasminogen activator (tPA). DIF: Cognitive Level: Apply (application) REF: 1401 | 1404 | 1398
c. Administer oxygen to keep O2 saturation >95%. OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
d. Use National Institute of Health Stroke Scale to assess patient. MSC: NCLEX: Physiological Integrity
Lewis Chapter 57_ Stroke Page 3 of 38
, Lewis Chapter 57_ Stroke 2/5/2026
A 68-year-old patient is being admitted with a possible stroke. ANS: C
Which information from the assessment indicates that the nurse A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is
should consult with the health care provider before giving the contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not
prescribed aspirin? contraindications to aspirin use, so the nurse can administer the aspirin.
a.
The patient has dysphasia. DIF: Cognitive Level: Apply (application) REF: 1392-1393
b. TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
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.
A 70-year-old female patient with left-sided hemiparesis arrives ANS: C
by ambulance to the emergency department. Which action The initial nursing action should be to assess the airway and take any needed actions to
should the nurse take first? ensure a patent airway. The other activities should take place quickly after the ABCs
a. (airway, breathing, and circulation) are completed.
Monitor the blood pressure.
b. DIF: Cognitive Level: Apply (application) REF: 1397-1398
Send the patient for a computed tomography (CT) scan. OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
c. MSC: NCLEX: Physiological Integrity
Check the respiratory rate and effort.
d.
Assess the Glasgow Coma Scale score.
Lewis Chapter 57_ Stroke Page 4 of 38
1st thing you do when you suspect a stroke Non-contrast CT scan (determines hemorrhagic vs ischemic)
4 major causes of hemorrhagic stroke 1)deep hypertensive intracerebral hemorrhages, 2)ruptured saccular aneurysms,
3)arteriovenous malformation,4)spontaneous lobar hemorrhages
A 40-year-old patient has a ruptured cerebral aneurysm and ANS: A
subarachnoid hemorrhage. Which intervention will be included The patient with a subarachnoid hemorrhage usually has minimal activity to prevent
in the care plan? cerebral vasospasm or further bleeding and is at risk for venous thromboembolism (VTE).
a. Activities such as coughing and sitting up that might increase intracranial pressure (ICP) or
Apply intermittent pneumatic compression stockings. decrease cerebral blood flow are avoided. Because there is no indication that the patient is
b. unconscious, an oropharyngeal airway is inappropriate.
Assist to dangle on edge of bed and assess for dizziness.
c. DIF: Cognitive Level: Apply (application) REF: 1405
Encourage patient to cough and deep breathe every 4 hours. TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
d.
Insert an oropharyngeal airway to prevent airway obstruction.
Lewis Chapter 57_ Stroke Page 1 of 38
,Lewis Chapter 57_ Stroke 2/5/2026
A 47-year-old patient will attempt oral feedings for the first time ANS: C
since having a stroke. The nurse should assess the gag reflex and The patient should be as upright as possible before attempting feeding to make swallowing
then easier and decrease aspiration risk. To assess swallowing ability, the nurse should initially
a. offer water or ice to the patient. Pureed diets are not recommended because the texture is
order a varied pureed diet. too smooth. The patient may have a poor appetite, but the oral feeding should be attempted
b. regardless.
assess the patient's appetite.
c. DIF: Cognitive Level: Apply (application) REF: 1406
assist the patient into a chair. TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
d.
offer the patient a sip of juice.
A 56-year-old patient arrives in the emergency department with ANS: D
hemiparesis and dysarthria that started 2 hours previously, and The patient's history and clinical manifestations suggest an acute ischemic stroke and a
health records show a history of several transient ischemic patient who is seen within 4.5 hours of stroke onset is likely to receive tPA (after screening
attacks (TIAs). The nurse anticipates preparing the patient for with a CT scan). Heparin administration in the emergency phase is not indicated. Emergent
a. carotid transluminal angioplasty or endarterectomy is not indicated for the patient who is
surgical endarterectomy. having an acute ischemic stroke.
b.
transluminal angioplasty. DIF: Cognitive Level: Apply (application) REF: 1391 | 1398
c. TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
intravenous heparin administration.
d.
tissue plasminogen activator (tPA) infusion.
Lewis Chapter 57_ Stroke Page 2 of 38
,Lewis Chapter 57_ Stroke 2/5/2026
A 58-year-old patient with a left-brain stroke suddenly bursts ANS: D
into tears when family members visit. The nurse should Patients who have left-sided brain stroke are prone to emotional outbursts that are not
a. necessarily related to the emotional state of the patient. Depression after a stroke is
use a calm voice to ask the patient to stop the crying behavior. common, but the suddenness of the patient's outburst suggests that depression is not the
b. major cause of the behavior. The family should stay with the patient. The crying is not
explain to the family that depression is normal following a within the patient's control and asking the patient to stop will lead to embarrassment.
stroke.
c. DIF: Cognitive Level: Apply (application) REF: 1409
have the family members leave the patient alone for a few TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
minutes.
d.
teach the family that emotional outbursts are common after
strokes.
A 63-year-old patient who began experiencing right arm and leg ANS:
weakness is admitted to the emergency department. In which C, D, A, B
order will the nurse implement these actions included in the The initial actions should be those that help with airway, breathing, and circulation. Baseline
stroke protocol? (Put a comma and a space between each answer neurologic assessments should be done next. A CT scan will be needed to rule out
choice [A, B, C, D].) hemorrhagic stroke before tPA can be administered.
a. Obtain computed tomography (CT) scan without contrast.
b. Infuse tissue plasminogen activator (tPA). DIF: Cognitive Level: Apply (application) REF: 1401 | 1404 | 1398
c. Administer oxygen to keep O2 saturation >95%. OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
d. Use National Institute of Health Stroke Scale to assess patient. MSC: NCLEX: Physiological Integrity
Lewis Chapter 57_ Stroke Page 3 of 38
, Lewis Chapter 57_ Stroke 2/5/2026
A 68-year-old patient is being admitted with a possible stroke. ANS: C
Which information from the assessment indicates that the nurse A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is
should consult with the health care provider before giving the contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not
prescribed aspirin? contraindications to aspirin use, so the nurse can administer the aspirin.
a.
The patient has dysphasia. DIF: Cognitive Level: Apply (application) REF: 1392-1393
b. TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
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.
A 70-year-old female patient with left-sided hemiparesis arrives ANS: C
by ambulance to the emergency department. Which action The initial nursing action should be to assess the airway and take any needed actions to
should the nurse take first? ensure a patent airway. The other activities should take place quickly after the ABCs
a. (airway, breathing, and circulation) are completed.
Monitor the blood pressure.
b. DIF: Cognitive Level: Apply (application) REF: 1397-1398
Send the patient for a computed tomography (CT) scan. OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
c. MSC: NCLEX: Physiological Integrity
Check the respiratory rate and effort.
d.
Assess the Glasgow Coma Scale score.
Lewis Chapter 57_ Stroke Page 4 of 38
