NCLEX MED SURG STROKE AND ANSWERS 2024
VERSION VERIFIED RATIONALE GRADED A+
1st thing you do when you suspect a stroke - ansNon-contrast CT scan (determines hemorrhagic vs
ischemic)
4 major causes of hemorrhagic stroke - ans1)deep hypertensive intracerebral hemorrhages, 2)ruptured
saccular aneurysms, 3)arteriovenous malformation,4)spontaneous lobar hemorrhages
A carotid endarterectomy is being considered as a treatment for a patient who has had several TIAs. The
nurse explains to the patient that this surgery
a. is used to restore blood to the brain following an obstruction of a cerebral artery
b. involves intracranial surgery to join a superficial extracranial artery to an intracranial artery
c. involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke
d. is sued to open a stenosis in a carotid artery with a balloon and stent to restore cerebral circulation -
ansC: Involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke-
An endarterectomy is a removal of an atherosclerotic plaque, and plaque in the carotid artery may
impair circulation enough to cause a stroke. A carotid endarterectomy is performed to prevent a
cerebrovascular accident (CVA), as are most other surgical procedures. An extacranial-intracranial bypass
involves cranial surgery to bypass a sclerotic intacranial artery. Percutaneous transluminal angioplasty
uses a balloon to compress stenotic areas in the carotid and vertebrobasilar arteries and often includes
inserting a stent to hold the artery open.
A diagnosis of a ruptured cerebral aneurysm has been made in a patient with manifestations of a stroke.
The nurse anticipates that treatment options that would be evaluated for the patient include
a. hyperventilation therapy
b. surgical clipping of the aneurysm
c. administration of hyperosmotic agents
d. administration of thrombolytic therapy - ansB: Surgical clipping of they aneurysm- Surgical
management with clipping of an aneurysm to decrease re bleeding and vasospasm is an option for a
stroke cause by rupture of a cerebral aneurysm. Placement of coils into the lumens of the aneurysm by
intercentional radiologists is increasing in popularity. Hyperventilation therapy would increase
vasodilation and the potential for hemorrhage. Thrombolytic therapy would be absolutely
contraindicated, and if a vessel is patent, osmotic diuretics may leak into tissue, pulling fluid out of the
vessel and increasing edema.
, NCLEX MED SURG STROKE AND ANSWERS 2024
VERSION VERIFIED RATIONALE GRADED A+
A newly admitted patient who has suffered a right sided brain stroke has a nursing diagnosis of disturbed
visual sensory perception related to homonymous hemianopsia. Early in the care of the patient, the
nurse should
a. place objects on the right side within the patient's field of vision
b. approach the patient from the left side to encourage the patient to turn the head
c. place objects on the patient's left side to assess the patient's ability to compensate
d. patch the affected eye to encourage the patient to turn the head to scan the environment - ansA:
Place objects on the right side within the patient's field of vision- the presence of homonymous
hemianopia in a patient with right-hemisphere brain damage causes a loss of vision in the left field. Early
in the care of the patient, objects should be placed on the right side of the patient in the field of vision,
and the nurse should approach the patient from the right side. Later in treatment, patients should be
taught to turn the head and scan the environment and should be approached from the affected side to
encourage head turning. Eye patches are used if patients have diplopia (double vision).
A nursing intervention is indicated for the patient with hemiplegia is
a. the use of a footboard to prevent plantar flexion
b. immobilization of the affected arm against the chest with a sling
c. positioning the patient in bed with each joint lower than the joint proximal to it
d. having the patient perform passive ROM of the affected limb with the unaffected limb - ansD: Having
the patient perform passive ROM of the affected limb with the unaffected limb- active ROM should be
initiated on the unaffected side as soon as possible, and passive ROM of the affected side should be
started on the first day. Having the patient actively exercise the unaffected side provides the patient with
active and passive ROM as needed. Use of footboards is controversial because they stimulate plantar
flexion. The unaffected arm should be supported, but immobilization may precipitate a painful shoulder-
hand syndrome. The patient should be positioned with each joint higher than the joint proximal to it to
prevent dependent edema.
A patient comes to the emergency department immediately after experiencing numbness of the face
and an inability to speak, but while the patient awaits examination, the symptoms disappear and the
patient request discharge. The nurse stresses that it is important for the patient to be evaluated
primarily because
VERSION VERIFIED RATIONALE GRADED A+
1st thing you do when you suspect a stroke - ansNon-contrast CT scan (determines hemorrhagic vs
ischemic)
4 major causes of hemorrhagic stroke - ans1)deep hypertensive intracerebral hemorrhages, 2)ruptured
saccular aneurysms, 3)arteriovenous malformation,4)spontaneous lobar hemorrhages
A carotid endarterectomy is being considered as a treatment for a patient who has had several TIAs. The
nurse explains to the patient that this surgery
a. is used to restore blood to the brain following an obstruction of a cerebral artery
b. involves intracranial surgery to join a superficial extracranial artery to an intracranial artery
c. involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke
d. is sued to open a stenosis in a carotid artery with a balloon and stent to restore cerebral circulation -
ansC: Involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke-
An endarterectomy is a removal of an atherosclerotic plaque, and plaque in the carotid artery may
impair circulation enough to cause a stroke. A carotid endarterectomy is performed to prevent a
cerebrovascular accident (CVA), as are most other surgical procedures. An extacranial-intracranial bypass
involves cranial surgery to bypass a sclerotic intacranial artery. Percutaneous transluminal angioplasty
uses a balloon to compress stenotic areas in the carotid and vertebrobasilar arteries and often includes
inserting a stent to hold the artery open.
A diagnosis of a ruptured cerebral aneurysm has been made in a patient with manifestations of a stroke.
The nurse anticipates that treatment options that would be evaluated for the patient include
a. hyperventilation therapy
b. surgical clipping of the aneurysm
c. administration of hyperosmotic agents
d. administration of thrombolytic therapy - ansB: Surgical clipping of they aneurysm- Surgical
management with clipping of an aneurysm to decrease re bleeding and vasospasm is an option for a
stroke cause by rupture of a cerebral aneurysm. Placement of coils into the lumens of the aneurysm by
intercentional radiologists is increasing in popularity. Hyperventilation therapy would increase
vasodilation and the potential for hemorrhage. Thrombolytic therapy would be absolutely
contraindicated, and if a vessel is patent, osmotic diuretics may leak into tissue, pulling fluid out of the
vessel and increasing edema.
, NCLEX MED SURG STROKE AND ANSWERS 2024
VERSION VERIFIED RATIONALE GRADED A+
A newly admitted patient who has suffered a right sided brain stroke has a nursing diagnosis of disturbed
visual sensory perception related to homonymous hemianopsia. Early in the care of the patient, the
nurse should
a. place objects on the right side within the patient's field of vision
b. approach the patient from the left side to encourage the patient to turn the head
c. place objects on the patient's left side to assess the patient's ability to compensate
d. patch the affected eye to encourage the patient to turn the head to scan the environment - ansA:
Place objects on the right side within the patient's field of vision- the presence of homonymous
hemianopia in a patient with right-hemisphere brain damage causes a loss of vision in the left field. Early
in the care of the patient, objects should be placed on the right side of the patient in the field of vision,
and the nurse should approach the patient from the right side. Later in treatment, patients should be
taught to turn the head and scan the environment and should be approached from the affected side to
encourage head turning. Eye patches are used if patients have diplopia (double vision).
A nursing intervention is indicated for the patient with hemiplegia is
a. the use of a footboard to prevent plantar flexion
b. immobilization of the affected arm against the chest with a sling
c. positioning the patient in bed with each joint lower than the joint proximal to it
d. having the patient perform passive ROM of the affected limb with the unaffected limb - ansD: Having
the patient perform passive ROM of the affected limb with the unaffected limb- active ROM should be
initiated on the unaffected side as soon as possible, and passive ROM of the affected side should be
started on the first day. Having the patient actively exercise the unaffected side provides the patient with
active and passive ROM as needed. Use of footboards is controversial because they stimulate plantar
flexion. The unaffected arm should be supported, but immobilization may precipitate a painful shoulder-
hand syndrome. The patient should be positioned with each joint higher than the joint proximal to it to
prevent dependent edema.
A patient comes to the emergency department immediately after experiencing numbness of the face
and an inability to speak, but while the patient awaits examination, the symptoms disappear and the
patient request discharge. The nurse stresses that it is important for the patient to be evaluated
primarily because
