NUR 2755 – Multidimensional Care IV (MDC 4)
Exam 1 Questions with Answers| Rasmussen
University| Updated| Pass Guaranteed
1. A client arrives at the ED with sudden left facial droop and slurred
speech. Which question is MOST important for the nurse to ask the
family?
A. "When did the client last eat?"
B. "What medications does the client take at home?"
C. "What time was the client last known to be normal?"
D. "Does anyone in the family have a history of stroke?"
Answer: C
Rationale: Thrombolytic (alteplase/tPA) eligibility depends on the time of
symptom onset or last known well: generally within 3 hours, and up to 4.5
hours for selected clients. All other data are useful but do not determine the
treatment window.
2. Which diagnostic test must be completed BEFORE a client with
suspected acute stroke receives a thrombolytic?
A. Noncontrast head CT
B. Carotid duplex ultrasound
C. Lumbar puncture
D. Electroencephalogram (EEG)
Answer: A
Rationale: A noncontrast CT quickly rules out intracranial hemorrhage.
Thrombolytics are contraindicated in hemorrhagic stroke because they
would worsen the bleeding.
NUR 2755 Exam 1– Page 1
,3. A client eligible for tPA has a BP of 210/115 mm Hg. Which action
does the nurse anticipate?
A. Hold all antihypertensives to preserve cerebral perfusion
B. Administer IV labetalol or nicardipine to lower BP below 185/110 mm
Hg before tPA
C. Give tPA immediately because the stroke is time-sensitive
D. Place the client in Trendelenburg position
Answer: B
Rationale: BP must be below 185/110 mm Hg before tPA and below
180/105 mm Hg for the first 24 hours afterward to reduce the risk of
intracranial hemorrhage.
4. Which nursing action is appropriate for a client who received tPA
30 minutes ago?
A. Administer aspirin as ordered for stroke prevention now
B. Perform neurologic checks and vital signs frequently (every 15 minutes
initially) and monitor for bleeding
C. Insert a nasogastric tube for medications
D. Encourage independent ambulation to regain function
Answer: B
Rationale: The major complication of tPA is bleeding, especially
intracranial. Antiplatelets/anticoagulants are held for 24 hours, and invasive
procedures (NG tubes, catheters, injections) are avoided. Sudden
headache, vomiting, decreased LOC, or rising BP requires stopping the
infusion and notifying the provider.
NUR 2755 Exam 1– Page 2
,5. Which manifestations does the nurse expect in a client with a LEFT
middle cerebral artery (MCA) stroke?
A. Left-sided neglect and impulsive behavior
B. Left-sided weakness with poor judgment
C. Right-sided hemiparesis and expressive aphasia
D. Bilateral blindness
Answer: C
Rationale: The left hemisphere controls the right side of the body and, in
most people, language. Left-brain strokes cause right-sided deficits and
aphasia; right-brain strokes cause left-sided deficits, neglect, and
impulsivity.
6. Which is the PRIORITY nursing concern for a client with a right-
hemisphere stroke?
A. Encouraging the client to transfer without assistance
B. Safety, because the client is impulsive, overestimates abilities, and
neglects the left side
C. Using a picture board for communication
D. Speaking in short sentences to promote comprehension
Answer: B
Rationale: Right-brain stroke causes poor judgment, impulsivity, and
unilateral neglect, all of which raise fall and injury risk. Communication aids
are more relevant to left-hemisphere (aphasia) strokes.
7. A client with Broca's (expressive) aphasia is frustrated. Which
approach is BEST?
A. Speak louder so the client can hear
B. Ask yes/no questions, allow extra time, and use gestures or picture
boards
C. Finish the client's sentences to reduce frustration
D. Avoid communication until speech therapy begins
NUR 2755 Exam 1– Page 3
, Answer: B
Rationale: In Broca's aphasia, comprehension is largely intact but speech
production is impaired. The client is not deaf or cognitively impaired;
patience and alternative communication methods preserve dignity.
8. A client admitted with an acute ischemic stroke is alert but has a
weak gag reflex and facial droop. What is the nurse's BEST action for
oral intake?
A. Provide ice chips for comfort
B. Offer thin liquids with a straw
C. Start a soft diet
D. Keep the client NPO until a swallow screen is passed
Answer: D
Rationale: Dysphagia puts the client at high risk for aspiration pneumonia.
The client remains NPO (including oral meds) until a formal swallow
screening or evaluation is passed.
9. A client with homonymous hemianopsia of the left visual field is
eating. Which teaching is BEST?
A. Approach from the left side to promote awareness
B. Turn the head to scan to the left and place the tray within the intact
(right) visual field
C. Keep the room dim to reduce visual stress
D. Place the tray on the client's left side
Answer: B
Rationale: Hemianopsia is loss of half of the visual field. Scanning by
turning the head compensates, and items are positioned in the intact field.
Approach from the intact side to avoid startling the client.
NUR 2755 Exam 1– Page 4
Exam 1 Questions with Answers| Rasmussen
University| Updated| Pass Guaranteed
1. A client arrives at the ED with sudden left facial droop and slurred
speech. Which question is MOST important for the nurse to ask the
family?
A. "When did the client last eat?"
B. "What medications does the client take at home?"
C. "What time was the client last known to be normal?"
D. "Does anyone in the family have a history of stroke?"
Answer: C
Rationale: Thrombolytic (alteplase/tPA) eligibility depends on the time of
symptom onset or last known well: generally within 3 hours, and up to 4.5
hours for selected clients. All other data are useful but do not determine the
treatment window.
2. Which diagnostic test must be completed BEFORE a client with
suspected acute stroke receives a thrombolytic?
A. Noncontrast head CT
B. Carotid duplex ultrasound
C. Lumbar puncture
D. Electroencephalogram (EEG)
Answer: A
Rationale: A noncontrast CT quickly rules out intracranial hemorrhage.
Thrombolytics are contraindicated in hemorrhagic stroke because they
would worsen the bleeding.
NUR 2755 Exam 1– Page 1
,3. A client eligible for tPA has a BP of 210/115 mm Hg. Which action
does the nurse anticipate?
A. Hold all antihypertensives to preserve cerebral perfusion
B. Administer IV labetalol or nicardipine to lower BP below 185/110 mm
Hg before tPA
C. Give tPA immediately because the stroke is time-sensitive
D. Place the client in Trendelenburg position
Answer: B
Rationale: BP must be below 185/110 mm Hg before tPA and below
180/105 mm Hg for the first 24 hours afterward to reduce the risk of
intracranial hemorrhage.
4. Which nursing action is appropriate for a client who received tPA
30 minutes ago?
A. Administer aspirin as ordered for stroke prevention now
B. Perform neurologic checks and vital signs frequently (every 15 minutes
initially) and monitor for bleeding
C. Insert a nasogastric tube for medications
D. Encourage independent ambulation to regain function
Answer: B
Rationale: The major complication of tPA is bleeding, especially
intracranial. Antiplatelets/anticoagulants are held for 24 hours, and invasive
procedures (NG tubes, catheters, injections) are avoided. Sudden
headache, vomiting, decreased LOC, or rising BP requires stopping the
infusion and notifying the provider.
NUR 2755 Exam 1– Page 2
,5. Which manifestations does the nurse expect in a client with a LEFT
middle cerebral artery (MCA) stroke?
A. Left-sided neglect and impulsive behavior
B. Left-sided weakness with poor judgment
C. Right-sided hemiparesis and expressive aphasia
D. Bilateral blindness
Answer: C
Rationale: The left hemisphere controls the right side of the body and, in
most people, language. Left-brain strokes cause right-sided deficits and
aphasia; right-brain strokes cause left-sided deficits, neglect, and
impulsivity.
6. Which is the PRIORITY nursing concern for a client with a right-
hemisphere stroke?
A. Encouraging the client to transfer without assistance
B. Safety, because the client is impulsive, overestimates abilities, and
neglects the left side
C. Using a picture board for communication
D. Speaking in short sentences to promote comprehension
Answer: B
Rationale: Right-brain stroke causes poor judgment, impulsivity, and
unilateral neglect, all of which raise fall and injury risk. Communication aids
are more relevant to left-hemisphere (aphasia) strokes.
7. A client with Broca's (expressive) aphasia is frustrated. Which
approach is BEST?
A. Speak louder so the client can hear
B. Ask yes/no questions, allow extra time, and use gestures or picture
boards
C. Finish the client's sentences to reduce frustration
D. Avoid communication until speech therapy begins
NUR 2755 Exam 1– Page 3
, Answer: B
Rationale: In Broca's aphasia, comprehension is largely intact but speech
production is impaired. The client is not deaf or cognitively impaired;
patience and alternative communication methods preserve dignity.
8. A client admitted with an acute ischemic stroke is alert but has a
weak gag reflex and facial droop. What is the nurse's BEST action for
oral intake?
A. Provide ice chips for comfort
B. Offer thin liquids with a straw
C. Start a soft diet
D. Keep the client NPO until a swallow screen is passed
Answer: D
Rationale: Dysphagia puts the client at high risk for aspiration pneumonia.
The client remains NPO (including oral meds) until a formal swallow
screening or evaluation is passed.
9. A client with homonymous hemianopsia of the left visual field is
eating. Which teaching is BEST?
A. Approach from the left side to promote awareness
B. Turn the head to scan to the left and place the tray within the intact
(right) visual field
C. Keep the room dim to reduce visual stress
D. Place the tray on the client's left side
Answer: B
Rationale: Hemianopsia is loss of half of the visual field. Scanning by
turning the head compensates, and items are positioned in the intact field.
Approach from the intact side to avoid startling the client.
NUR 2755 Exam 1– Page 4
