NUR 400 Final Exam NCLEX Style
Questions with answers
Which nursing intervention takes priority when assessing
the neurological health of a patient who has just been
admitted with a suspected stroke?
a. Assessing patient for injury (wounds, bruising, bone
breaks)
b. Performing a comprehensive neurological assessment
c. Administering tissue plasminogen activator (tPA)
d. Obtaining a detailed medical history
b. Performing a comprehensive neurological assessment
Rationale:
Assessing the client for injury (option A) is important in
the overall assessment of a client, but it is not the
priority. Neurological assessment takes precedence
because timely identification of neurological deficits is
crucial for determining the type and severity of the stroke
and guiding subsequent interventions.
,Administering tissue plasminogen activator (tPA) (option
C) is a time-sensitive intervention for ischemic strokes,
but it should only be initiated after a comprehensive
neurological assessment and confirmation of eligibility
criteria. Administering tPA without proper assessment
may pose risks to the client.
Obtaining a detailed medical history (option D) is
essential in understanding the client's risk factors and
medical background, but it is not the priority intervention
upon admission of a client with a suspected stroke.
Performing a comprehensive neurological assessment
(option B) is the priority because it allows for the timely
identification of neurological deficits, such as asymmetry
in strength, sensation, coordination, and changes in level
of consciousness. This assessment guides further
diagnostic testing, treatment decisions, and interventions
to promote optimal outcomes for the client.
An 86 year old patient with a history of hypertension
comes to the Emergency Department confused and
complaining of a severe headache. The nurse is
concerned that the patient is having a stroke. Which
action does the nurse take first?
a. Obtain a full set of vitals
,b. Perform a Mini Mental Status Exam
c. Assess the patient using the Glasgow Coma Scale
d. Ask the patient to smile, speak their name, and then
hold out their arms
d. Ask the patient to smile, speak their name, and then
hold out their arms
Rationale:
To assess for a stroke the nurse should determine if the
patient is experiencing face paralysis using the "FAST"
technique:
F > facial drooping and uneven smile
A > arm weakness, inability to lift both arms
S > speech difficulty, inability to repeat a simple
sentence
T > time, seek immediate care or intervention.
Although vital signs can be useful, they do not give a
more focused assessment regarding brain insult. Vital
signs can be obtained after the FAST technique is used.
The Mini Mental Status Exam is used to assess cognitive
impairment, so it would not be useful in determining the
status of the patient at this time. The Glasgow Coma
Scale is used to determine level of consciousness and is
, not appropriate as an initial assessment because the
client is currently conscious.
A nurse is assessing the neurological status of a patient
who has been admitted following a motor vehicle
accident. Which assessment finding should the nurse
prioritize as an indication of potential increased
intracranial pressure (ICP)?
a. Dilated pupils with sluggish response to light
b. Unequal movement of extremities
c. Decreased blood pressure with increased heart rate
d. Increased respiratory rate with shallow breathing
a. Dilated pupils with sluggish response to light
Rationale:
The correct answer is A because dilated pupils with
sluggish response to light as an indication of potential
increased intracranial pressure (ICP). Pupillary changes,
Questions with answers
Which nursing intervention takes priority when assessing
the neurological health of a patient who has just been
admitted with a suspected stroke?
a. Assessing patient for injury (wounds, bruising, bone
breaks)
b. Performing a comprehensive neurological assessment
c. Administering tissue plasminogen activator (tPA)
d. Obtaining a detailed medical history
b. Performing a comprehensive neurological assessment
Rationale:
Assessing the client for injury (option A) is important in
the overall assessment of a client, but it is not the
priority. Neurological assessment takes precedence
because timely identification of neurological deficits is
crucial for determining the type and severity of the stroke
and guiding subsequent interventions.
,Administering tissue plasminogen activator (tPA) (option
C) is a time-sensitive intervention for ischemic strokes,
but it should only be initiated after a comprehensive
neurological assessment and confirmation of eligibility
criteria. Administering tPA without proper assessment
may pose risks to the client.
Obtaining a detailed medical history (option D) is
essential in understanding the client's risk factors and
medical background, but it is not the priority intervention
upon admission of a client with a suspected stroke.
Performing a comprehensive neurological assessment
(option B) is the priority because it allows for the timely
identification of neurological deficits, such as asymmetry
in strength, sensation, coordination, and changes in level
of consciousness. This assessment guides further
diagnostic testing, treatment decisions, and interventions
to promote optimal outcomes for the client.
An 86 year old patient with a history of hypertension
comes to the Emergency Department confused and
complaining of a severe headache. The nurse is
concerned that the patient is having a stroke. Which
action does the nurse take first?
a. Obtain a full set of vitals
,b. Perform a Mini Mental Status Exam
c. Assess the patient using the Glasgow Coma Scale
d. Ask the patient to smile, speak their name, and then
hold out their arms
d. Ask the patient to smile, speak their name, and then
hold out their arms
Rationale:
To assess for a stroke the nurse should determine if the
patient is experiencing face paralysis using the "FAST"
technique:
F > facial drooping and uneven smile
A > arm weakness, inability to lift both arms
S > speech difficulty, inability to repeat a simple
sentence
T > time, seek immediate care or intervention.
Although vital signs can be useful, they do not give a
more focused assessment regarding brain insult. Vital
signs can be obtained after the FAST technique is used.
The Mini Mental Status Exam is used to assess cognitive
impairment, so it would not be useful in determining the
status of the patient at this time. The Glasgow Coma
Scale is used to determine level of consciousness and is
, not appropriate as an initial assessment because the
client is currently conscious.
A nurse is assessing the neurological status of a patient
who has been admitted following a motor vehicle
accident. Which assessment finding should the nurse
prioritize as an indication of potential increased
intracranial pressure (ICP)?
a. Dilated pupils with sluggish response to light
b. Unequal movement of extremities
c. Decreased blood pressure with increased heart rate
d. Increased respiratory rate with shallow breathing
a. Dilated pupils with sluggish response to light
Rationale:
The correct answer is A because dilated pupils with
sluggish response to light as an indication of potential
increased intracranial pressure (ICP). Pupillary changes,
