Question 1

A patient is being admitted with a possible stroke. Which information from the assessment indicates that the nurse should consult with the health care provider before giving the prescribed aspirin?

Accepted Answer

A)  The patient has dysphasia.
B)  The patient has atrial fibrillation.
C)  The patient reports that symptoms began with a severe headache.
D)  The patient has a history of brief episodes of right-sided hemiplegia. C

Question 2

A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which response by the nurse is accurate?

Accepted Answer

A)  "The obstructing plaque is surgically removed from inside an artery in the neck."
B)  "The diseased portion of the artery in the brain is replaced with a synthetic graft."
C)  "A wire is threaded through an artery in the leg to the clots in the carotid artery, and the clots are removed."
D)  "A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to flatten the plaque." A

Question 3

A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities. The nurse observes that when the patient's wife is visiting,she feeds and dresses him. Which nursing diagnosis is most appropriate for the patient?

Accepted Answer

A)  Interrupted family processes related to effects of illness of a family member
B)  Situational low self-esteem related to increasing dependence on spouse for care
C)  Disabled family coping related to inadequate understanding by patient's spouse
D)  Impaired nutrition: less than body requirements related to hemiplegia and aphasia C

Question 4

The home health nurse is caring for an 81-yr-old who had a stroke 2 months ago. Based on information shown in the accompanying figure from the history,physical assessment,and physical and occupational therapy,which problem is the highest priority?

Accepted Answer

A)  Risk for hypoglycemia
B)  Impaired transfer ability
C)  Risk for caregiver role strain
D)  Ineffective health maintenance

Question 5

The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)?

Accepted Answer

A)  Assess the patient's gag and cough reflexes.
B)  Determine when the stroke symptoms began.
C)  Administer the prescribed short-acting insulin.
D)  Infuse the prescribed IV metoprolol (Lopressor) .

Question 6

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness. Which patient problem do they determine has the highest priority for the patient?

Accepted Answer

A)  Impaired physical mobility related to weakness
B)  Disturbed sensory perception related to brain injury
C)  Risk for impaired skin integrity related to immobility
D)  Risk for aspiration related to inability to protect airway

Question 7

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?

Accepted Answer

A)  Complete blood count (CB
C)  
B)  Chest radiograph (chest x-ray) 
C)  Computed tomography (CT)  scan
D)  12-Lead electrocardiogram (ECG)

Question 8

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?

Accepted Answer

A)  The patient's speech is difficult to understand.
B)  The patient's blood pressure (BP)  is 144/90 mm Hg.
C)  The patient takes a diuretic because of a history of hypertension.
D)  The patient has atrial fibrillation and takes warfarin (Coumadin) .

Question 9

Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider?

Accepted Answer

A)  The patient complains of having a stiff neck.
B)  The patient's blood pressure (BP)  is 90/50 mm Hg.
C)  The patient reports a severe and unrelenting headache.
D)  The cerebrospinal fluid (CSF)  report shows red blood cells (RBCs) .

Question 10

After a patient experienced a brief episode of tinnitus,diplopia,and dysarthria with no residual effects,the nurse anticipates teaching the patient about

Accepted Answer

A)  cerebral aneurysm clipping.
B)  heparin intravenous infusion.
C)  oral low-dose aspirin therapy.
D)  tissue plasminogen activator (tP
A)  .

Question 11

A 63-yr-old patient who began experiencing right arm and leg weakness is admitted to the emergency department. In which order will the nurse implement these actions included in the stroke protocol? (Put a comma and a space between each answer choice [A,B,C,D].)

Accepted Answer

A)  Obtain CT scan without contrast.
B)  Infuse tissue plasminogen activator (tP
A)  .
C)  Administer oxygen to keep O? saturation >95%.
D)  Use National Institute of Health Stroke Scale to assess patient.

Question 12

A patient will attempt oral feedings for the first time after having a stroke. The nurse should assess the gag reflex and then

Accepted Answer

A)  order a varied pureed diet.
B)  assess the patient's appetite.
C)  assist the patient into a chair.
D)  offer the patient a sip of juice.

Question 13

A 70-yr-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?

Accepted Answer

A)  Take the patient's blood pressure.
B)  Check the respiratory rate and effort.
C)  Assess the Glasgow Coma Scale score.
D)  Send the patient for a computed tomography (CT)  scan.

Question 14

Several weeks after a stroke,a 50-yr-old male patient has impaired awareness of bladder fullness,resulting in urinary incontinence. Which nursing intervention should be planned to begin an effective bladder training program?

Accepted Answer

A)  Limit fluid intake to 1200 mL daily to reduce urine volume.
B)  Assist the patient onto the bedside commode every 2 hours.
C)  Perform intermittent catheterization after each voiding to check for residual urine.
D)  Use an external "condom" catheter to protect the skin and prevent embarrassment.

Question 15

After receiving change-of-shift report on the following four patients,which patient should the nurse see first?

Accepted Answer

A)  A 60-yr-old patient with right-sided weakness who has an infusion of tPA prescribed
B)  A 50-yr-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) 
C)  A 30-yr-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine scheduled
D)  A 40-yr-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due

Question 16

During the change of shift report,a nurse is told that a patient has an occluded left posterior cerebral artery. The nurse will anticipate that the patient may have

Accepted Answer

A)  dysphasia.
B)  confusion.
C)  visual deficits.
D)  poor judgment.

Question 17

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?

Accepted Answer

A)  Apply an eye patch to the right eye.
B)  Approach the patient from the right side.
C)  Place needed objects on the patient's left side.
D)  Teach the patient that the left visual deficit will resolve.

Question 18

Which stroke risk factor for a 48-yr-old male patient in the clinic is most important for the nurse to address?

Accepted Answer

A)  The patient is 25 lb 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.

Question 19

When teaching about clopidogrel (Plavix),the nurse will tell the patient with cerebral atherosclerosis

Accepted Answer

A)  to monitor and record the blood pressure daily.
B)  to call the health care provider if stools are tarry.
C)  that clopidogrel will dissolve clots in the cerebral arteries.
D)  that clopidogrel will reduce cerebral artery plaque formation.

Question 20

A left-handed patient with left-sided hemiplegia has difficulty feeding himself. Which intervention should the nurse include in the plan of care?

Accepted Answer

A)  Provide a wide variety of food choices.
B)  Provide oral care before and after meals.
C)  Assist the patient to eat with the right hand.
D)  Teach the patient the "chin-tuck" technique.

Exam 57: Stroke