STROKE- NCLEX EXAM QUESTIONS AND CORRECT
ANSWER WITH RATIONALE, WITH COMPLETE SOLUTION
2024/2025.
The nurse is caring for a patient with a history of transient ischemic attacks
(TIAs) and moderate carotid stenosis who has undergone a carotid
endarterectomy. Which of the following postoperative findings would cause the
nurse the most concern?
a) Blood pressure (BP): 128/86 mm Hg
b) Neck pain: 3/10 (0 to 10 pain scale)
c) Mild neck edema
d) Difficulty swallowing
Difficulty swallowing
The patient's inability to swallow without difficulty would cause the nurse the most
concern. Difficulty in swallowing, hoarseness or other signs of cranial nerve dysfunction
must be assessed. The nurse focuses on assessment of the following cranial nerves:
facial (VII), vagus (X), spinal accessory (XI), and hypoglossal (XII). Some edema in the
neck after surgery is expected; however, extensive edema and hematoma formation
can obstruct the airway. Emergency airway supplies, including those needed for a
tracheostomy, must be available. The patient's neck pain and mild BP elevation need
addressing but would not cause the nurse the most concern. Hypotension is avoided to
prevent cerebral ischemia and thrombosis. Uncontrolled hypertension may precipitate
cerebral hemorrhage, edema, hemorrhage at the surgical incision, or disruption of the
arterial reconstruction.
An emergency department nurse is interviewing a client with signs of an ischemic
stroke that began 2 hours ago. The client reports that she had a cholecystectomy
6 weeks ago and is taking digoxin, coumadin, and labetelol. This client is not
eligible for thrombolytic therapy for which of the following reasons?
a) She is not within the treatment time window.
b) She had surgery 6 weeks ago.
c) She is taking digoxin.
d) She is taking coumadin.
,She is taking coumadin.
To be eligible for thrombolytic therapy, the client cannot be taking coumadin. Initiation of
thrombolytic therapy must be within 3 hours in clients with ischemic stroke. The client is
not eligible for thrombolytic therapy if she has had surgery within 14 days. Digoxin and
labetelol do not prohibit thrombolytic therapy.
Which disturbance results in loss of half of the visual field?
a) Anisocoria
b) Homonymous hemianopsia
c) Nystagmus
d) Diplopia
Homonymous hemianopsia
Homonymous hemianopsia (loss of half of the visual field) may occur from stroke and
may be temporary or permanent. Double vision is documented as diplopia. Nystagmus
is ocular bobbing and may be seen in multiple sclerosis. Anisocoria is unequal pupils.
A client with a cerebrovascular accident (CVA) is having difficulty with eating
food on the plate. Which is the best nursing action to be taken?
a) Reposition the tray and plate.
b) Perform a vision field assessment.
c) Know this is a normal finding for CVA.
d) Assist the client with feeding.
Perform a vision field assessment.
The nurse should perform a vision field assessment to evaluate the client
forhemianopia. This finding could indicate damage to the visual area of the brain as a
result of evolving CVA. Repositioning the tray and assisting with feeding would not be
the best nursing action until new finding has been evaluated. Hemianopia can be
associated with a CVA but, when presenting as a new finding, should be evaluated and
reported immediately. (less)
A client is hospitalized when they present to the Emergency Department with
right-sided weakness. Within 6 hours of being admitted, the neurologic deficits
had resolved and the client was back to their presymptomatic state. The nurse
caring for the client knows that the probable cause of the neurologic deficit was
what?
,a) Cerebral aneurysm
b) Transient ischemic attack
c) Left-sided stroke
d) Right-sided stroke
Transient ischemic attack
A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment
caused by a temporary interruption in cerebral blood flow. Symptoms may disappear
within 1 hour; some continue for as long as 1 day. When the symptoms terminate, the
client resumes his or her presymptomatic state. The symptoms do not describe a left- or
right-sided stroke or a cerebral aneurysm.
Which of the following terms refer to the failure to recognize familiar objects
perceived by the senses?
a) Agnosia
b) Perseveration
c) Apraxia
d) Agraphia
Agnosia
Auditory agnosia is failure to recognize significance of sounds. Agraphia refers to
disturbances in writing intelligible words. Apraxia refers to inability to perform previously
learned purposeful motor acts on a voluntary basis. Perseveration is the continued and
automatic repetition of an activity, word, or phrase that is no longer appropriate.
During a class on stroke, a junior nursing student asks what the clinical
manifestations of stroke are. What would be the instructor's best answer?
a) "Clinical manifestations of a stroke depend on the area of the cortex, the
affected hemisphere, the degree of blockage, and the availability of collateral
circulation."
b) "Clinical manifestations of a stroke generally include aphasia, one-sided
flaccidity, and trouble swallowing."
c) "Clinical manifestations of a stroke depend on how quickly the clot can be
dissolved."
, d) "Clinical manifestations of a stroke are highly variable, depending on the
cardiovascular health of the client."
"Clinical manifestations of a stroke depend on the area of the cortex, the affected
hemisphere, the degree of blockage, and the availability of collateral circulation."
Clinical manifestations following a stroke are highly variable and depend on the area of
the cerebral cortex and the affected hemisphere, the degree of blockage (total, partial),
and the presence or absence of adequate collateral circulation. (Collateral circulation is
circulation formed by smaller blood vessels branching off from or near larger occluded
vessels.) Clinical manifestations of a stroke do not depend on the cardiovascular health
of the client or how quickly the clot can be dissolved. Clinical manifestations of a stroke
are not "general" but individual.
When communicating with a client who has sensory (receptive) aphasia, the
nurse should:
a) speak loudly and articulate clearly.
b) allow time for the client to respond.
c) give the client a writing pad.
d) use short, simple sentences.
use short, simple sentences.
Although sensory aphasia allows the client to hear words, it impairs the ability to
comprehend their meaning. The nurse should use short, simple sentences to promote
comprehension. Allowing time for the client to respond might be helpful but is less
important than simplifying the communication. Because the client's hearing isn't
affected, speaking loudly isn't necessary. A writing pad is helpful for clients with
expressive, not receptive, aphasia.
The nurse is providing information about strokes to a community group. Which of
the following would the nurse identify as the primary initial symptoms of an
ischemic stroke?
a) Footdrop and external hip rotation
b) Vomiting and seizures
c) Severe headache and early change in level of consciousness
d) Weakness on one side of the body and difficulty with speech
Weakness on one side of the body and difficulty with speech
The main presenting symptoms for an ischemic stroke are numbness or weakness of
ANSWER WITH RATIONALE, WITH COMPLETE SOLUTION
2024/2025.
The nurse is caring for a patient with a history of transient ischemic attacks
(TIAs) and moderate carotid stenosis who has undergone a carotid
endarterectomy. Which of the following postoperative findings would cause the
nurse the most concern?
a) Blood pressure (BP): 128/86 mm Hg
b) Neck pain: 3/10 (0 to 10 pain scale)
c) Mild neck edema
d) Difficulty swallowing
Difficulty swallowing
The patient's inability to swallow without difficulty would cause the nurse the most
concern. Difficulty in swallowing, hoarseness or other signs of cranial nerve dysfunction
must be assessed. The nurse focuses on assessment of the following cranial nerves:
facial (VII), vagus (X), spinal accessory (XI), and hypoglossal (XII). Some edema in the
neck after surgery is expected; however, extensive edema and hematoma formation
can obstruct the airway. Emergency airway supplies, including those needed for a
tracheostomy, must be available. The patient's neck pain and mild BP elevation need
addressing but would not cause the nurse the most concern. Hypotension is avoided to
prevent cerebral ischemia and thrombosis. Uncontrolled hypertension may precipitate
cerebral hemorrhage, edema, hemorrhage at the surgical incision, or disruption of the
arterial reconstruction.
An emergency department nurse is interviewing a client with signs of an ischemic
stroke that began 2 hours ago. The client reports that she had a cholecystectomy
6 weeks ago and is taking digoxin, coumadin, and labetelol. This client is not
eligible for thrombolytic therapy for which of the following reasons?
a) She is not within the treatment time window.
b) She had surgery 6 weeks ago.
c) She is taking digoxin.
d) She is taking coumadin.
,She is taking coumadin.
To be eligible for thrombolytic therapy, the client cannot be taking coumadin. Initiation of
thrombolytic therapy must be within 3 hours in clients with ischemic stroke. The client is
not eligible for thrombolytic therapy if she has had surgery within 14 days. Digoxin and
labetelol do not prohibit thrombolytic therapy.
Which disturbance results in loss of half of the visual field?
a) Anisocoria
b) Homonymous hemianopsia
c) Nystagmus
d) Diplopia
Homonymous hemianopsia
Homonymous hemianopsia (loss of half of the visual field) may occur from stroke and
may be temporary or permanent. Double vision is documented as diplopia. Nystagmus
is ocular bobbing and may be seen in multiple sclerosis. Anisocoria is unequal pupils.
A client with a cerebrovascular accident (CVA) is having difficulty with eating
food on the plate. Which is the best nursing action to be taken?
a) Reposition the tray and plate.
b) Perform a vision field assessment.
c) Know this is a normal finding for CVA.
d) Assist the client with feeding.
Perform a vision field assessment.
The nurse should perform a vision field assessment to evaluate the client
forhemianopia. This finding could indicate damage to the visual area of the brain as a
result of evolving CVA. Repositioning the tray and assisting with feeding would not be
the best nursing action until new finding has been evaluated. Hemianopia can be
associated with a CVA but, when presenting as a new finding, should be evaluated and
reported immediately. (less)
A client is hospitalized when they present to the Emergency Department with
right-sided weakness. Within 6 hours of being admitted, the neurologic deficits
had resolved and the client was back to their presymptomatic state. The nurse
caring for the client knows that the probable cause of the neurologic deficit was
what?
,a) Cerebral aneurysm
b) Transient ischemic attack
c) Left-sided stroke
d) Right-sided stroke
Transient ischemic attack
A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment
caused by a temporary interruption in cerebral blood flow. Symptoms may disappear
within 1 hour; some continue for as long as 1 day. When the symptoms terminate, the
client resumes his or her presymptomatic state. The symptoms do not describe a left- or
right-sided stroke or a cerebral aneurysm.
Which of the following terms refer to the failure to recognize familiar objects
perceived by the senses?
a) Agnosia
b) Perseveration
c) Apraxia
d) Agraphia
Agnosia
Auditory agnosia is failure to recognize significance of sounds. Agraphia refers to
disturbances in writing intelligible words. Apraxia refers to inability to perform previously
learned purposeful motor acts on a voluntary basis. Perseveration is the continued and
automatic repetition of an activity, word, or phrase that is no longer appropriate.
During a class on stroke, a junior nursing student asks what the clinical
manifestations of stroke are. What would be the instructor's best answer?
a) "Clinical manifestations of a stroke depend on the area of the cortex, the
affected hemisphere, the degree of blockage, and the availability of collateral
circulation."
b) "Clinical manifestations of a stroke generally include aphasia, one-sided
flaccidity, and trouble swallowing."
c) "Clinical manifestations of a stroke depend on how quickly the clot can be
dissolved."
, d) "Clinical manifestations of a stroke are highly variable, depending on the
cardiovascular health of the client."
"Clinical manifestations of a stroke depend on the area of the cortex, the affected
hemisphere, the degree of blockage, and the availability of collateral circulation."
Clinical manifestations following a stroke are highly variable and depend on the area of
the cerebral cortex and the affected hemisphere, the degree of blockage (total, partial),
and the presence or absence of adequate collateral circulation. (Collateral circulation is
circulation formed by smaller blood vessels branching off from or near larger occluded
vessels.) Clinical manifestations of a stroke do not depend on the cardiovascular health
of the client or how quickly the clot can be dissolved. Clinical manifestations of a stroke
are not "general" but individual.
When communicating with a client who has sensory (receptive) aphasia, the
nurse should:
a) speak loudly and articulate clearly.
b) allow time for the client to respond.
c) give the client a writing pad.
d) use short, simple sentences.
use short, simple sentences.
Although sensory aphasia allows the client to hear words, it impairs the ability to
comprehend their meaning. The nurse should use short, simple sentences to promote
comprehension. Allowing time for the client to respond might be helpful but is less
important than simplifying the communication. Because the client's hearing isn't
affected, speaking loudly isn't necessary. A writing pad is helpful for clients with
expressive, not receptive, aphasia.
The nurse is providing information about strokes to a community group. Which of
the following would the nurse identify as the primary initial symptoms of an
ischemic stroke?
a) Footdrop and external hip rotation
b) Vomiting and seizures
c) Severe headache and early change in level of consciousness
d) Weakness on one side of the body and difficulty with speech
Weakness on one side of the body and difficulty with speech
The main presenting symptoms for an ischemic stroke are numbness or weakness of
