STROKE QUESTIONS AND ADVANCED
ANSWERS
The neurologist also prescribes a magnetic resonance imaging (MRI) of the head STAT. Which data
warrants immediate intervention by the nurse concerning this diagnostic test?
A. Allergy to shellfish
B. History of atrial fibrillation
C. Right hip replacement
D. Elevated blood pressure ANSW✅✅C. Right hip replacement
-The magnetic field generated by the MRI is so strong that metal-containing items are strongly
attracted to the magnet. Because the hip joint is made of metal, a lead shield must be used during
the procedure.
Nancy is transferred to the Intermediate Care Unit after the MRI is completed. She has a 20 gauge
saline lock in her right forearm and an 18 French indwelling (Foley) catheter. Gail is sitting by her
mother's bed. The nurse asks Gail if there is anyone that can be called so she won't be alone. She
informs the nurse that she is an only child and her father died years ago. Gail states, "I don't
understand what a brain attack is. The healthcare provider told me my mother is in serious condition
and they are going to run several tests. I just don't know what's going on. What happened to my
mother?" Which response is best by the nurse?
A. "How do you feel about what the healthcare provider said?"
B. "Your mother has had a stroke, and the blood supply to the brain has been compromised."
C. "I will call the healthcare provider so he/she can talk to you about your mother's serious
condition."
D. "I am sorry, but what happene ANSW✅✅B. "Your mother has had a stroke, and the blood
supply to the brain has been compromised."
-The nurse has the knowledge, and the responsibility, to explain Nancy's condition to Gail.
Gail starts to cry and states, "Mom was just fine last week when we went out to eat and to a show. I
love my mom so much, and I am so scared. She is all I have." How should the nurse respond?
A. "I am sure everything will be all right."
B. "I will notify the chaplain to come and sit with you so you won't be alone."
C. "I know this is scary for you. Would you like to sit and talk?"
C. "I am sure your mother knows you are here. Just keep talking to her." ANSW✅✅C. "I know this
is scary for you. Would you like to sit and talk?
, -This therapeutic response provides acknowledgment of Gail's fears, and the nurse offers to take
time to discuss the situation.
With a diagnosis of a brain attack (stroke), which priority intervention should the nurse include in
Nancy's plan of care?
A. Monitor INR daily
B. Assess neurological status every shift
C. Keep the head of the bed elevated
D. Evaluate platelet levels daily ANSW✅✅C. Keep the head of the bed elevated
- Maintaining a patent airway is essential to support oxygenation and cerebral perfusion. Elevating
the head of the bed 30 degrees aids in preventing the tongue from falling backward and obstructing
the airway.
The nurse continues to monitor Nancy's condition closely. Which finding would require immediate
intervention by the nurse?
A. Nancy's pulse oximeter reading is greater than 95%
B. Nancy's serum potassium level is 3.9 mEq/L
C. Nancy's telemetry shows normal sinus rhythm with occasional premature ventricular contractions
D. Nancy's cardiac output is less than 4 L/min ANSW✅✅D. Nancy's cardiac output is less than 4
L/min
- The normal range for cardiac output to ensure cerebral blood flow and oxygen delivery is 4 to 8
L/min.
Though Nancy's SaO2 potassium level, and telemetry readings are within normal limits for her age,
her cardiac output is low. Which nursing interventions would be priority at this time?
A. Monitor capillary refill every 2-4 hours
B. Monitor level of consciousness
C. Monitor vital signs every shift
D. Strict intake and output
E. Contact physician ANSW✅✅A. Monitor capillary refill every 2-4 hours
- Decreased cardiac output would affect tissue perfusion, reflected in a capillary refill of greater than
3 seconds.
B. Monitor level of consciousness
ANSWERS
The neurologist also prescribes a magnetic resonance imaging (MRI) of the head STAT. Which data
warrants immediate intervention by the nurse concerning this diagnostic test?
A. Allergy to shellfish
B. History of atrial fibrillation
C. Right hip replacement
D. Elevated blood pressure ANSW✅✅C. Right hip replacement
-The magnetic field generated by the MRI is so strong that metal-containing items are strongly
attracted to the magnet. Because the hip joint is made of metal, a lead shield must be used during
the procedure.
Nancy is transferred to the Intermediate Care Unit after the MRI is completed. She has a 20 gauge
saline lock in her right forearm and an 18 French indwelling (Foley) catheter. Gail is sitting by her
mother's bed. The nurse asks Gail if there is anyone that can be called so she won't be alone. She
informs the nurse that she is an only child and her father died years ago. Gail states, "I don't
understand what a brain attack is. The healthcare provider told me my mother is in serious condition
and they are going to run several tests. I just don't know what's going on. What happened to my
mother?" Which response is best by the nurse?
A. "How do you feel about what the healthcare provider said?"
B. "Your mother has had a stroke, and the blood supply to the brain has been compromised."
C. "I will call the healthcare provider so he/she can talk to you about your mother's serious
condition."
D. "I am sorry, but what happene ANSW✅✅B. "Your mother has had a stroke, and the blood
supply to the brain has been compromised."
-The nurse has the knowledge, and the responsibility, to explain Nancy's condition to Gail.
Gail starts to cry and states, "Mom was just fine last week when we went out to eat and to a show. I
love my mom so much, and I am so scared. She is all I have." How should the nurse respond?
A. "I am sure everything will be all right."
B. "I will notify the chaplain to come and sit with you so you won't be alone."
C. "I know this is scary for you. Would you like to sit and talk?"
C. "I am sure your mother knows you are here. Just keep talking to her." ANSW✅✅C. "I know this
is scary for you. Would you like to sit and talk?
, -This therapeutic response provides acknowledgment of Gail's fears, and the nurse offers to take
time to discuss the situation.
With a diagnosis of a brain attack (stroke), which priority intervention should the nurse include in
Nancy's plan of care?
A. Monitor INR daily
B. Assess neurological status every shift
C. Keep the head of the bed elevated
D. Evaluate platelet levels daily ANSW✅✅C. Keep the head of the bed elevated
- Maintaining a patent airway is essential to support oxygenation and cerebral perfusion. Elevating
the head of the bed 30 degrees aids in preventing the tongue from falling backward and obstructing
the airway.
The nurse continues to monitor Nancy's condition closely. Which finding would require immediate
intervention by the nurse?
A. Nancy's pulse oximeter reading is greater than 95%
B. Nancy's serum potassium level is 3.9 mEq/L
C. Nancy's telemetry shows normal sinus rhythm with occasional premature ventricular contractions
D. Nancy's cardiac output is less than 4 L/min ANSW✅✅D. Nancy's cardiac output is less than 4
L/min
- The normal range for cardiac output to ensure cerebral blood flow and oxygen delivery is 4 to 8
L/min.
Though Nancy's SaO2 potassium level, and telemetry readings are within normal limits for her age,
her cardiac output is low. Which nursing interventions would be priority at this time?
A. Monitor capillary refill every 2-4 hours
B. Monitor level of consciousness
C. Monitor vital signs every shift
D. Strict intake and output
E. Contact physician ANSW✅✅A. Monitor capillary refill every 2-4 hours
- Decreased cardiac output would affect tissue perfusion, reflected in a capillary refill of greater than
3 seconds.
B. Monitor level of consciousness
