STROKE QUESTIONS AND CERTIFIED
SOLUTIONS
Which modifiable risk factors for stroke would be most important for the nurse to include when
planning a community education program?
A. Hypertension
B. Hyperlipidemia
C. Alcohol consumption
D. Oral contraceptive use ANSW✅✅a
hypertension is the single most important modifiable risk factor.
The nurse is planning care for a client with right-sided weakness and aphasia from a transient
ischemic attack (TIA). Which area of the brain should the nurse realize was affected in this client?
a. medulla
b. occipital lobe
c. left hemisphere
d. right hemisphere ANSW✅✅ANS:C
Symptom onset is sudden and generally involves one side of the bodythe side of the body opposite
to the damaged area. A. B. The manifestations of right-sided weakness and aphasia would not be
present if the TIA occurred in the medulla or occipital lobe. D. The client would have left-sided
manifestations if the TIA occurred in the right hemisphere.
A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency
department. Which action should the nurse take first?
a. Monitor the blood pressure.
b. Send the patient for a computed tomography (CT) scan.
c. Check the respiratory rate and effort.
d. Assess the Glasgow Coma Scale score. ANSW✅✅c
the initial nursing action should be to assess airway and take any needed actions to esnure a patent
airway
,the nurse is assisting with teaching a patient who has had a transient ischemic attack (TIA). On which
understanding should the nurse base teaching?
a. tias are not serious, and the patient should have no further problems
b. a tia is predictive that the patient will have a heart attack with in 1 year
c. a tia is a medical emergency that requires immediate surgical intervention
d. a tia is a forewarning that the patient is at risk for a cerbrovascular accident ANSW✅✅ANS d
About a third of patients who experience a TIA will have a stroke in the future. A. Urgent evaluation
of TIA is essential in order to decrease the risk of stroke. B. There are no data related to myocardial
infarction (MI) prediction. C. It is not a surgical problem.
A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency
department and diagnostic tests are ordered. Which test should be done first?
a. Complete blood count (CBC)
b. Chest radiograph (Chest x-ray)
c. 12-Lead electrocardiogram (ECG)
d. Noncontrast computed tomography (CT) scan ANSW✅✅D. Rapid screening with a noncontrast
CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given
within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the
less brain injury. The other diagnostic tests give information about possible causes of the stroke and
do not need to be completed as urgently as the CT scan.
A patient with a cerebrovascular accident (stroke) has left-sided flaccidity and is unable to speak but
seems to understand everything the nurse says. Which term should the nurse use to document the
patients communication impairment?
a. sensory aphasia
b. motor dysphagia
c. expressive aphasia
d. receptive dysphagia ANSW✅✅ANS:C
Aphasia may be expressive, in which the patient knows what he or she wants to say but cannot
speak or make sense. D. Receptive aphasia is an inability to understand spoken or written words.
The patient experiencing receptive aphasia is unable to understand language. B. Dysphagia refers to
difficulty swallowing. A. Sensory aphasia is not a type of communication impairment.
Which stroke risk factor for a 48-year-old male patient in the clinic is most important for the nurse to
address?
, a. The patient is 25 pounds above the ideal weight.
b. The patient drinks a glass of red wine with dinner daily.
c. The patient's usual blood pressure (BP) is 170/94 mm Hg.
d. The patient works at a desk and relaxes by watching television. ANSW✅✅C. Hypertension is the
single most important modifiable risk factor. People who drink more than 1 (for women) or 2 (for
men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity
contribute to stroke risk but not as much as hypertension
Which patient being cared for in the emergency department should the charge nurse evaluate first?
a a patient with a complete spinal injury at c5 dermatome level
b. a patient with a glasgow coma scale score of 15 on 3 L nasal cannula
c. an alert patient with a subdural bleed who is complaining of a headache
d. an ischemic stroke patient with a blood pressure of 190/100 mmHg ANSW✅✅ANS: A
A patient with a C5 complete spinal injury is at risk for ineffective breathing patterns and should be
assessed immediately for any airway compromise. A GCS score of 15 indicates a neurologically intact
patient. The patient with a subdural bleed is alert and not in danger of any immediate compromise.
The goal for ischemic stroke is to keep the systolic BP less than 220 mm Hg and the diastolic blood
pressure less than 120 mm Hg.
When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke,
which intervention should the nurse include in the plan of care?
a. Apply an eye patch to the right eye.
b. Approach the patient from the right side.
c. Place objects needed on the patient's left side.
d. Teach the patient that the left visual deficit will resolve. ANSW✅✅C. During the acute period,
the nurse should place objects on the patient's unaffected side. Because there is a visual defect in
the right half of each eye, an eye patch is not appropriate. The patient should be approached from
the left side. The visual deficit may not resolve, although the patient can learn to compensate for the
defect.
the nurse is reviewing teaching provided to a patient with transient ischemic attack (TIA). Which
statement indicates that further teaching is required?
a. the risk factors and symptoms of a tia are just like those of a stroke
b. i need to stop smoking to help lower my chances of this happenning again
c. my risk for alzheimers disease is increased now so ill have to stop driving
SOLUTIONS
Which modifiable risk factors for stroke would be most important for the nurse to include when
planning a community education program?
A. Hypertension
B. Hyperlipidemia
C. Alcohol consumption
D. Oral contraceptive use ANSW✅✅a
hypertension is the single most important modifiable risk factor.
The nurse is planning care for a client with right-sided weakness and aphasia from a transient
ischemic attack (TIA). Which area of the brain should the nurse realize was affected in this client?
a. medulla
b. occipital lobe
c. left hemisphere
d. right hemisphere ANSW✅✅ANS:C
Symptom onset is sudden and generally involves one side of the bodythe side of the body opposite
to the damaged area. A. B. The manifestations of right-sided weakness and aphasia would not be
present if the TIA occurred in the medulla or occipital lobe. D. The client would have left-sided
manifestations if the TIA occurred in the right hemisphere.
A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency
department. Which action should the nurse take first?
a. Monitor the blood pressure.
b. Send the patient for a computed tomography (CT) scan.
c. Check the respiratory rate and effort.
d. Assess the Glasgow Coma Scale score. ANSW✅✅c
the initial nursing action should be to assess airway and take any needed actions to esnure a patent
airway
,the nurse is assisting with teaching a patient who has had a transient ischemic attack (TIA). On which
understanding should the nurse base teaching?
a. tias are not serious, and the patient should have no further problems
b. a tia is predictive that the patient will have a heart attack with in 1 year
c. a tia is a medical emergency that requires immediate surgical intervention
d. a tia is a forewarning that the patient is at risk for a cerbrovascular accident ANSW✅✅ANS d
About a third of patients who experience a TIA will have a stroke in the future. A. Urgent evaluation
of TIA is essential in order to decrease the risk of stroke. B. There are no data related to myocardial
infarction (MI) prediction. C. It is not a surgical problem.
A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency
department and diagnostic tests are ordered. Which test should be done first?
a. Complete blood count (CBC)
b. Chest radiograph (Chest x-ray)
c. 12-Lead electrocardiogram (ECG)
d. Noncontrast computed tomography (CT) scan ANSW✅✅D. Rapid screening with a noncontrast
CT scan is needed before administration of tissue plasminogen activator (tPA), which must be given
within 4.5 hours of the onset of clinical manifestations of the stroke. The sooner the tPA is given, the
less brain injury. The other diagnostic tests give information about possible causes of the stroke and
do not need to be completed as urgently as the CT scan.
A patient with a cerebrovascular accident (stroke) has left-sided flaccidity and is unable to speak but
seems to understand everything the nurse says. Which term should the nurse use to document the
patients communication impairment?
a. sensory aphasia
b. motor dysphagia
c. expressive aphasia
d. receptive dysphagia ANSW✅✅ANS:C
Aphasia may be expressive, in which the patient knows what he or she wants to say but cannot
speak or make sense. D. Receptive aphasia is an inability to understand spoken or written words.
The patient experiencing receptive aphasia is unable to understand language. B. Dysphagia refers to
difficulty swallowing. A. Sensory aphasia is not a type of communication impairment.
Which stroke risk factor for a 48-year-old male patient in the clinic is most important for the nurse to
address?
, a. The patient is 25 pounds above the ideal weight.
b. The patient drinks a glass of red wine with dinner daily.
c. The patient's usual blood pressure (BP) is 170/94 mm Hg.
d. The patient works at a desk and relaxes by watching television. ANSW✅✅C. Hypertension is the
single most important modifiable risk factor. People who drink more than 1 (for women) or 2 (for
men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and obesity
contribute to stroke risk but not as much as hypertension
Which patient being cared for in the emergency department should the charge nurse evaluate first?
a a patient with a complete spinal injury at c5 dermatome level
b. a patient with a glasgow coma scale score of 15 on 3 L nasal cannula
c. an alert patient with a subdural bleed who is complaining of a headache
d. an ischemic stroke patient with a blood pressure of 190/100 mmHg ANSW✅✅ANS: A
A patient with a C5 complete spinal injury is at risk for ineffective breathing patterns and should be
assessed immediately for any airway compromise. A GCS score of 15 indicates a neurologically intact
patient. The patient with a subdural bleed is alert and not in danger of any immediate compromise.
The goal for ischemic stroke is to keep the systolic BP less than 220 mm Hg and the diastolic blood
pressure less than 120 mm Hg.
When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke,
which intervention should the nurse include in the plan of care?
a. Apply an eye patch to the right eye.
b. Approach the patient from the right side.
c. Place objects needed on the patient's left side.
d. Teach the patient that the left visual deficit will resolve. ANSW✅✅C. During the acute period,
the nurse should place objects on the patient's unaffected side. Because there is a visual defect in
the right half of each eye, an eye patch is not appropriate. The patient should be approached from
the left side. The visual deficit may not resolve, although the patient can learn to compensate for the
defect.
the nurse is reviewing teaching provided to a patient with transient ischemic attack (TIA). Which
statement indicates that further teaching is required?
a. the risk factors and symptoms of a tia are just like those of a stroke
b. i need to stop smoking to help lower my chances of this happenning again
c. my risk for alzheimers disease is increased now so ill have to stop driving
