Stroke Certification Study Guide For Nurses (Stroke- Nclex) ||
Accurate Answers With Rationale
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
ans: d
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.
ans: d
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
ans: b.
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.
ans: b.
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
ans: b
, 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
ans: a
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."
Accurate Answers With Rationale
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
ans: d
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.
ans: d
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
ans: b.
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.
ans: b.
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
ans: b
, 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
ans: a
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."
