NSG 3250 NURSING PRACTICE ADULT HEALTH 1 EXAM 3
A client is brought to the emergency department with a suspected stroke. Which assessment finding is
most suggestive of a stroke?
A) Severe headache with photophobia
B) Facial droop and arm weakness on one side
C) Nausea and vomiting
D) Dizziness and vertigo
Correct Answer: Facial droop and arm weakness on one side
Rationale: The FAST (Face, Arm, Speech, Time) mnemonic is used for rapid stroke assessment . Facial
droop and arm weakness are classic signs of a stroke . Severe headache, nausea, and dizziness can occur
but are not as specific as unilateral motor deficits.
A client diagnosed with an ischemic stroke is receiving thrombolytic therapy with alteplase (tPA). The
nurse should immediately stop the infusion and notify the provider if the client develops which finding?
A) Mild headache
B) Severe headache, severe hypertension, or signs of bleeding
C) Nausea and vomiting
D) Heart rate of 88 beats/min
Correct Answer: Severe headache, severe hypertension, or signs of bleeding
Rationale: Alteplase (tPA) increases the risk of bleeding, including intracranial hemorrhage. Signs such as
a severe headache, severe hypertension, bleeding, or change in LOC are indicators to stop the infusion .
The nurse must monitor for these complications.
A client is scheduled for a carotid endarterectomy after experiencing transient ischemic attacks (TIAs).
What is the primary purpose of this procedure?
A) To repair a cerebral aneurysm
B) To remove atherosclerotic plaques blocking cerebral blood flow
,C) To relieve increased intracranial pressure
D) To bypass a blocked coronary artery
Correct Answer: To remove atherosclerotic plaques blocking cerebral blood flow
Rationale: A carotid endarterectomy is performed to remove atherosclerotic plaques from the carotid
artery, which improves cerebral blood flow and reduces the risk of stroke . This procedure is indicated
for clients with symptomatic carotid stenosis.
A client has experienced an ischemic stroke and has been admitted to the medical unit. To best prevent
joint deformities, the nurse should implement which intervention?
A) Place a pillow under the client's knees
B) Place a pillow in the axilla when there is limited external rotation
C) Position the client in a prone position for 30 minutes each shift
D) Perform passive range-of-motion exercises once daily
Correct Answer: Place a pillow in the axilla when there is limited external rotation
Rationale: Correct positioning with a pillow in the axilla prevents adduction and internal rotation of the
shoulder, reducing the risk of joint deformities and contractures . Other measures include frequent
repositioning and range of motion exercises.
A client is 24 hours post-ischemic stroke and has not received tPA. The nurse should monitor for which
potential complication in the immediate recovery period?
A) Dehydration
B) Cerebral edema and increased intracranial pressure
C) Hyperglycemia
D) Seizures
Correct Answer: Cerebral edema and increased intracranial pressure
,Rationale: Cerebral edema is a common and serious complication after an ischemic stroke, often peaking
24-72 hours after onset. It increases intracranial pressure and can cause further neurologic deterioration
.
A client is diagnosed with a hemorrhagic stroke. What is the nurse's priority goal when creating this
client's plan of care?
A) Maintaining and improving cerebral tissue perfusion
B) Initiating early ambulation
C) Preventing constipation
D) Administering anticoagulant therapy
Correct Answer: Maintaining and improving cerebral tissue perfusion
Rationale: In a hemorrhagic stroke, bleeding in the brain compromises cerebral perfusion. The priority is
to maintain and improve cerebral tissue perfusion by managing blood pressure, preventing further
bleeding, and controlling ICP . Anticoagulants are contraindicated.
Which of the following findings is an early sign of neurological deterioration in a client with a
hemorrhagic stroke?
A) Sudden increase in blood pressure
B) Alteration in level of consciousness (LOC)
C) New onset of headache
D) Fever
Correct Answer: Alteration in level of consciousness (LOC)
Rationale: An alteration in level of consciousness is one of the earliest and most sensitive indicators of
neurological deterioration, increased intracranial pressure, or re-bleeding in a client with a hemorrhagic
stroke . Frequent neuro checks are essential.
A client with a right-sided stroke exhibits impulsive behavior and impaired judgment. The nurse
understands these findings are characteristic of which type of stroke?
, A) Left hemisphere stroke
B) Right hemisphere stroke
C) Brainstem stroke
D) Cerebellar stroke
Correct Answer: Right hemisphere stroke
Rationale: Right-sided strokes often result in left-sided weakness, perceptual deficits, impulsive
behavior, poor judgment, and a short attention span . Left hemisphere strokes typically affect language
and analytical skills.
A client who suffered a stroke has homonymous hemianopsia. How can the nurse best help the client
manage this sensory-perceptual deficit?
A) Approach the client from the side with visual perception intact
B) Place all objects on the client's affected side
C) Instruct the client to close their eyes when walking
D) Keep the client in a dark room to prevent overstimulation
Correct Answer: Approach the client from the side with visual perception intact
Rationale: Homonymous hemianopsia is the loss of half of the visual field in both eyes. To compensate,
the nurse should approach the client from the side where visual perception is intact . This helps the
client see the caregiver and reduces startle or anxiety.
A client is NPO before surgery but is prescribed phenytoin for a seizure disorder. What should the nurse
do to ensure the client receives the medication?
A) Administer the medication with a sip of water
B) Hold the medication until the client can eat
C) Give the medication via IV or contact the provider for a different prescription
D) Crush the pill and mix it with applesauce
A client is brought to the emergency department with a suspected stroke. Which assessment finding is
most suggestive of a stroke?
A) Severe headache with photophobia
B) Facial droop and arm weakness on one side
C) Nausea and vomiting
D) Dizziness and vertigo
Correct Answer: Facial droop and arm weakness on one side
Rationale: The FAST (Face, Arm, Speech, Time) mnemonic is used for rapid stroke assessment . Facial
droop and arm weakness are classic signs of a stroke . Severe headache, nausea, and dizziness can occur
but are not as specific as unilateral motor deficits.
A client diagnosed with an ischemic stroke is receiving thrombolytic therapy with alteplase (tPA). The
nurse should immediately stop the infusion and notify the provider if the client develops which finding?
A) Mild headache
B) Severe headache, severe hypertension, or signs of bleeding
C) Nausea and vomiting
D) Heart rate of 88 beats/min
Correct Answer: Severe headache, severe hypertension, or signs of bleeding
Rationale: Alteplase (tPA) increases the risk of bleeding, including intracranial hemorrhage. Signs such as
a severe headache, severe hypertension, bleeding, or change in LOC are indicators to stop the infusion .
The nurse must monitor for these complications.
A client is scheduled for a carotid endarterectomy after experiencing transient ischemic attacks (TIAs).
What is the primary purpose of this procedure?
A) To repair a cerebral aneurysm
B) To remove atherosclerotic plaques blocking cerebral blood flow
,C) To relieve increased intracranial pressure
D) To bypass a blocked coronary artery
Correct Answer: To remove atherosclerotic plaques blocking cerebral blood flow
Rationale: A carotid endarterectomy is performed to remove atherosclerotic plaques from the carotid
artery, which improves cerebral blood flow and reduces the risk of stroke . This procedure is indicated
for clients with symptomatic carotid stenosis.
A client has experienced an ischemic stroke and has been admitted to the medical unit. To best prevent
joint deformities, the nurse should implement which intervention?
A) Place a pillow under the client's knees
B) Place a pillow in the axilla when there is limited external rotation
C) Position the client in a prone position for 30 minutes each shift
D) Perform passive range-of-motion exercises once daily
Correct Answer: Place a pillow in the axilla when there is limited external rotation
Rationale: Correct positioning with a pillow in the axilla prevents adduction and internal rotation of the
shoulder, reducing the risk of joint deformities and contractures . Other measures include frequent
repositioning and range of motion exercises.
A client is 24 hours post-ischemic stroke and has not received tPA. The nurse should monitor for which
potential complication in the immediate recovery period?
A) Dehydration
B) Cerebral edema and increased intracranial pressure
C) Hyperglycemia
D) Seizures
Correct Answer: Cerebral edema and increased intracranial pressure
,Rationale: Cerebral edema is a common and serious complication after an ischemic stroke, often peaking
24-72 hours after onset. It increases intracranial pressure and can cause further neurologic deterioration
.
A client is diagnosed with a hemorrhagic stroke. What is the nurse's priority goal when creating this
client's plan of care?
A) Maintaining and improving cerebral tissue perfusion
B) Initiating early ambulation
C) Preventing constipation
D) Administering anticoagulant therapy
Correct Answer: Maintaining and improving cerebral tissue perfusion
Rationale: In a hemorrhagic stroke, bleeding in the brain compromises cerebral perfusion. The priority is
to maintain and improve cerebral tissue perfusion by managing blood pressure, preventing further
bleeding, and controlling ICP . Anticoagulants are contraindicated.
Which of the following findings is an early sign of neurological deterioration in a client with a
hemorrhagic stroke?
A) Sudden increase in blood pressure
B) Alteration in level of consciousness (LOC)
C) New onset of headache
D) Fever
Correct Answer: Alteration in level of consciousness (LOC)
Rationale: An alteration in level of consciousness is one of the earliest and most sensitive indicators of
neurological deterioration, increased intracranial pressure, or re-bleeding in a client with a hemorrhagic
stroke . Frequent neuro checks are essential.
A client with a right-sided stroke exhibits impulsive behavior and impaired judgment. The nurse
understands these findings are characteristic of which type of stroke?
, A) Left hemisphere stroke
B) Right hemisphere stroke
C) Brainstem stroke
D) Cerebellar stroke
Correct Answer: Right hemisphere stroke
Rationale: Right-sided strokes often result in left-sided weakness, perceptual deficits, impulsive
behavior, poor judgment, and a short attention span . Left hemisphere strokes typically affect language
and analytical skills.
A client who suffered a stroke has homonymous hemianopsia. How can the nurse best help the client
manage this sensory-perceptual deficit?
A) Approach the client from the side with visual perception intact
B) Place all objects on the client's affected side
C) Instruct the client to close their eyes when walking
D) Keep the client in a dark room to prevent overstimulation
Correct Answer: Approach the client from the side with visual perception intact
Rationale: Homonymous hemianopsia is the loss of half of the visual field in both eyes. To compensate,
the nurse should approach the client from the side where visual perception is intact . This helps the
client see the caregiver and reduces startle or anxiety.
A client is NPO before surgery but is prescribed phenytoin for a seizure disorder. What should the nurse
do to ensure the client receives the medication?
A) Administer the medication with a sip of water
B) Hold the medication until the client can eat
C) Give the medication via IV or contact the provider for a different prescription
D) Crush the pill and mix it with applesauce
