NCLEX EXAM zm
Exam Solution zm
58 Stroke Lippincotts 2026 A+ GRADE ASSURED COMP
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LETE SOLUTIONS AND VERIFIED ANSWERS (85326)
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QUESTION 1 zm
A client is being monitored for transient ischemic attacks. She is oriented, can open h
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er eyes spontaneously, and follows commands. What is her Glasgow Coma Scale score?
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_____________points.
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ANSWER
15 points The Glasgow Coma Scale provides three objective neurologic assessments: spontaneity of e
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ye opening, best motor response, and best verbal response on a scale of 3 to 15. The client who sco
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res the best on all three assessments scores 15 points.
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QUESTION 2 zm
A client arrives in the emergency department with an ischemic stroke and receives tis
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sue plasminogen activator (t-
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PA) administration. The nurse should first: 1. Ask what medications the client is takin
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g. 2. Complete a history and health assessment. 3. Identify the time of onset of the str
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oke. 4. Determine if the client is scheduled for any surgical procedures.
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ANSWER
3. Studies show that clients who receive recombinant t-
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PA treatment within 3 hours after the onset of a stroke have better outcomes. The time from the on
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set of a stroke to t-
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PA treatment is critical. A complete health assessment and history is not possible when a client is r
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eceiving emergency care. Upcoming surgical procedures may need to be delayed because of the admi
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nistration of t- zm zm
PA, which is a priority in the immediate treatment of the current stroke. While the nurse should ide
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ntify which medications the client is taking, it is more important to know the time of the onset of t
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he stroke to determine the course of action for administering t-PA.
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QUESTION 3 zm
, During the first 24 hours after thrombolytic treatment for an ischemic stroke, the pri
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mary goal is to control the client's: 1. Pulse. 2. Respirations. 3. Blood pressure. 4. Tem
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perature.
ANSWER
3. Control of blood pressure is critical during the first 24 hours after treatment because an intracere
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bral hemorrhage is the major adverse effect of thrombolytic therapy. Vital signs are monitored, and
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blood pressure is maintained as identified by the physician and specific to the client's ischemic tissu
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e needs and risk of bleeding from treatment. The other vital signs are important, but the priority is
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to monitor blood pressure.
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QUESTION 4 zm
What is a priority nursing assessment in the first 24 hours after admission of the clie
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nt with a thrombotic stroke? 1. Cholesterol level. 2. Pupil size and pupillary response.
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3. Bowel sounds. 4. Echocardiogram.
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ANSWER
2. It is crucial to monitor the pupil size and pupillary response to indicate changes around the crani
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al nerves. The cholesterol level is not a priority assessment, although it may be an assessment to be
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maddressed for long- zm zm
term healthy lifestyle rehabilitation. Bowel sounds need to be assessed because an ileus or constipat
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ion can develop, but this is not a priority in the first 24 hours, when the primary concerns are cere
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bral hemorrhage and increased intracranial pressure. An echocardiogram is not needed for the client
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with a thrombotic stroke without heart problems.
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QUESTION 5 zm
In planning care for the client who has had a stroke, the nurse should obtain a histor
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y of the client's functional status before the stroke because? 1. The rehabilitation plan
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mwill be guided by it. 2. Functional status before the stroke will help predict outcomes.
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m3. It will help the client recognize his physical limitations. 4. The client can be expect
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ed to regain much of his functioning.
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ANSWER
1. The primary reason for the nursing assessment of a client's functional status before and after a st
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roke is to guide the plan. The assessment does not help to predict how far the rehabilitation team c
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an help the client to recover from the residual effects of the stroke, only what plans can help a clie
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nt who has moved from one functional level to another. The nursing assessment of the client's funct
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ional status is not a motivating factor.
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QUESTION 6 zm
Which of the following techniques does the nurse avoid when changing a client's posit
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ion in bed if the client has hemiparalysis? 1. Rolling the client onto the side. 2. Sliding
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Exam Solution zm
58 Stroke Lippincotts 2026 A+ GRADE ASSURED COMP
zm zm zm zm zm zm zm
LETE SOLUTIONS AND VERIFIED ANSWERS (85326)
zm zm zm zm zm
QUESTION 1 zm
A client is being monitored for transient ischemic attacks. She is oriented, can open h
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
er eyes spontaneously, and follows commands. What is her Glasgow Coma Scale score?
zm zm zm zm zm zm zm zm zm zm zm zm
_____________points.
zm
ANSWER
15 points The Glasgow Coma Scale provides three objective neurologic assessments: spontaneity of e
zm zm zm zm zm zm zm zm zm zm zm zm zm
ye opening, best motor response, and best verbal response on a scale of 3 to 15. The client who sco
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
res the best on all three assessments scores 15 points.
zm zm zm zm zm zm zm zm zm
QUESTION 2 zm
A client arrives in the emergency department with an ischemic stroke and receives tis
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sue plasminogen activator (t-
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PA) administration. The nurse should first: 1. Ask what medications the client is takin
zm zm zm zm zm zm zm zm zm zm zm zm zm
g. 2. Complete a history and health assessment. 3. Identify the time of onset of the str
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
oke. 4. Determine if the client is scheduled for any surgical procedures.
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ANSWER
3. Studies show that clients who receive recombinant t-
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PA treatment within 3 hours after the onset of a stroke have better outcomes. The time from the on
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set of a stroke to t-
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PA treatment is critical. A complete health assessment and history is not possible when a client is r
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
eceiving emergency care. Upcoming surgical procedures may need to be delayed because of the admi
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nistration of t- zm zm
PA, which is a priority in the immediate treatment of the current stroke. While the nurse should ide
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ntify which medications the client is taking, it is more important to know the time of the onset of t
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he stroke to determine the course of action for administering t-PA.
zm zm zm zm zm zm zm zm zm zm
QUESTION 3 zm
, During the first 24 hours after thrombolytic treatment for an ischemic stroke, the pri
zm zm zm zm zm zm zm zm zm zm zm zm zm
mary goal is to control the client's: 1. Pulse. 2. Respirations. 3. Blood pressure. 4. Tem
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
perature.
ANSWER
3. Control of blood pressure is critical during the first 24 hours after treatment because an intracere
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
bral hemorrhage is the major adverse effect of thrombolytic therapy. Vital signs are monitored, and
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
blood pressure is maintained as identified by the physician and specific to the client's ischemic tissu
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
e needs and risk of bleeding from treatment. The other vital signs are important, but the priority is
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to monitor blood pressure.
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QUESTION 4 zm
What is a priority nursing assessment in the first 24 hours after admission of the clie
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nt with a thrombotic stroke? 1. Cholesterol level. 2. Pupil size and pupillary response.
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3. Bowel sounds. 4. Echocardiogram.
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ANSWER
2. It is crucial to monitor the pupil size and pupillary response to indicate changes around the crani
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al nerves. The cholesterol level is not a priority assessment, although it may be an assessment to be
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maddressed for long- zm zm
term healthy lifestyle rehabilitation. Bowel sounds need to be assessed because an ileus or constipat
zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ion can develop, but this is not a priority in the first 24 hours, when the primary concerns are cere
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
bral hemorrhage and increased intracranial pressure. An echocardiogram is not needed for the client
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with a thrombotic stroke without heart problems.
zm zm zm zm zm zm zm
QUESTION 5 zm
In planning care for the client who has had a stroke, the nurse should obtain a histor
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y of the client's functional status before the stroke because? 1. The rehabilitation plan
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mwill be guided by it. 2. Functional status before the stroke will help predict outcomes.
zm zm zm zm zm zm zm zm zm zm zm zm zm zm z
m3. It will help the client recognize his physical limitations. 4. The client can be expect
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ed to regain much of his functioning.
zm zm zm zm zm zm
ANSWER
1. The primary reason for the nursing assessment of a client's functional status before and after a st
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
roke is to guide the plan. The assessment does not help to predict how far the rehabilitation team c
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
an help the client to recover from the residual effects of the stroke, only what plans can help a clie
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
nt who has moved from one functional level to another. The nursing assessment of the client's funct
zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm zm
ional status is not a motivating factor.
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QUESTION 6 zm
Which of the following techniques does the nurse avoid when changing a client's posit
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ion in bed if the client has hemiparalysis? 1. Rolling the client onto the side. 2. Sliding
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