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1. The nurse obtains all of the following information about a 65-year-old patient
in the clinic. When developing a plan to decrease stroke risk, which risk factor is
most important for the nurse to address?
a. The patient smokes a pack of cigarettes daily.
b. The patient's blood pressure (BP) is chronically between 150/80 to 170/90 mm
Hg.
c. The patient works at a desk and relaxes by watching television.
d. The patient is 25 pounds above the ideal weight. - ANSWER - Correct Answer: B
Rationale: Hypertension is the most important modifiable risk factor. Smoking,
physical inactivity, and obesity all contribute to stroke risk but not so much as
hypertension.
Cognitive Level: Application Text Reference: p. 1503
Nursing Process: Assessment
NCLEX: Health Promotion and Maintenance
2. A patient with right-sided weakness that started 1 hour ago is admitted to the
emergency department and all these diagnostic tests are ordered. Which order
should the nurse act on first?
a. Noncontrast computed tomography (CT) scan
b. Chest radiograph
,c. Complete blood count (CBC)
d. Electrocardiogram (ECG) - ANSWER - Correct Answer: A
Rationale: Rapid screening with a noncontrast CT scan is needed before
administration of tissue plasminogen activator (tPA), which must be given within
3 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is
given, the smaller the area of brain injury. The other diagnostic tests give
information about possible causes of the stroke and do not need to be completed
as urgently as the CT scan.
Cognitive Level: Application Text Reference: pp. 1509, 1511-1512
Nursing Process: Implementation NCLEX: Physiological Integrity
3. The nurse expects that management of the patient who experiences a brief
episode of tinnitus, diplopia, and dysarthria with no residual effects will include
a. heparin via continuous intravenous infusion.
b. prophylactic clipping of cerebral aneurysms.
c. therapy with tissue plasminogen activator (tPA).
d. oral administration of ticlopidine (Ticlid). - ANSWER - Correct Answer: D
Rationale: The patient's symptoms are consistent with transient ischemic attack
(TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to
prevent stroke. Continuous heparin infusion is not routinely used after TIA or with
acute ischemic stroke. The patient's symptoms are not consistent with a cerebral
aneurysm. tPA is used only for acute ischemic stroke, but not for TIA.
Cognitive Level: Application Text Reference: p. 1505
Nursing Process: Implementation NCLEX: Physiological Integrity
, 4. Aspirin is ordered for a patient who is admitted with a possible stroke. Which
information obtained during the admission assessment indicates that the nurse
should consult with the health care provider before giving the aspirin?
a. The patient has atrial fibrillation.
b. The patient has dysphasia.
c. The patient states, "I suddenly developed a terrible headache."
d. The patient has a history of brief episodes of right hemiplegia. - ANSWER -
Correct Answer: C
Rationale: A sudden-onset headache is typical of a subarachnoid hemorrhage, and
aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic
attack (TIA) are not contraindications to aspirin use, so the nurse can administer
the aspirin.
Cognitive Level: Application Text Reference: p. 1507
Nursing Process: Assessment NCLEX: Physiological Integrity
5. A patient with a stroke experiences right-sided arm and leg paralysis and facial
drooping on the right side. When obtaining admission assessment data about the
patient's clinical manifestations, it is most important the nurse assess the
patient's
a. ability to follow commands.
b. visual fields.
c. right-sided reflexes. - ANSWER - d. emotional state.
Correct Answer: A