Advanced Practice Nursing in the Care of Older
Adults / Edition 2 2025 Brand New!!!
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
c. Left hemisphere
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 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
c. Expressive aphasia
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.
The nurse is documenting care provided to a patient with left-sided flaccidity caused by a stroke.
Which term should the nurse use to document this patients motor status?
a. Ipsilateral paraplegia
b. Ipsilateral hemiparesis
c. Contralateral hemiplegia
d. Contralateral quadriparesis
, c. Contralateral hemiplegia
A patient with a stroke has symptoms on the opposite side of the stroke, which is called
contralateral. One-sided flaccidity is called hemiplegia. A. Ipsilateral means the same side. Para
refers to the lower extremities. D. Quad refers to all four extremities; B. Hemiparesis is another
term for hemiplegia.
A patient comes into the emergency department with symptoms of a stroke. Which medication
should the nurse expect may be given to the patient if diagnostic testing confirms an ischemic stroke?
a. Heparin
b. Clopidogrel (Plavix)
c. Warfarin (Coumadin)
d. Tissue-type plasminogen activator (tPA)
d. Tissue-type plasminogen activator (tPA)
tPA is a thrombolytic agent that can break down the thrombus causing the occlusion, which can
potentially prevent or completely reverse the symptoms of an ischemic stroke. A. B. C. Heparin,
warfarin, and clopidogrel can help prevent clots but are not effective in breaking up an existing
clot.
A patient is prescribed an antiplatelet agent to prevent strokes. Which agent was this patient most
likely prescribed?
a. Aspirin
b. Warfarin (Coumadin)
c. Acetaminophen (Tylenol)
d. Tissue-type plasminogen activator (tPA)
Aspirin
Aspirin is a platelet aggregation inhibitor. C. Tylenol is an analgesic but does not affect platelet
function. B. Warfarin is an anticoagulant. D. tPA is a thrombolytic agent.
A patient with symptoms of impending stroke is scheduled to have a cerebral angiogram. Which
statement should the nurse include when assisting with patient teaching?
a. This test is designed to detect vascular lesions in the brain.
b. The angiogram is done to help identify swelling in the brain.
c. We need to do this to evaluate electrical function of the brain.
d. This test is done to examine cerebrospinal fluid for signs of bleeding.
This test is designed to detect vascular lesions in the brain.
A cerebral angiogram may be completed to determine the patency of cerebral vessels and the
status of any collateral circulation. D. A lumbar puncture is done to examine cerebrospinal fluid
, (CSF). B. Edema may be identified by radiography. C. An electroencephalogram (EEG) shows
electrical function.
The nurse is caring for a hospitalized patient who has had a stroke and is waiting to be transferred to a
rehabilitation facility. What nursing action can best maximize the patients rehabilitation potential
while awaiting the transfer?
a. Teach the patient what to expect at the rehabilitation facility.
b. Keep the patient on bedrest to conserve energy for rehabilitation.
c. Call the physical therapist for bedside rehabilitation until the transfer.
d. Turn the patient every 2 hours to prevent pressure ulcers and contractures.
c. Call the physical therapist for bedside rehabilitation until the transfer.
Rehabilitation should begin as soon as the patient is stable. Waiting until the patient is at the
rehabilitation facility to begin therapy wastes valuable time. A. Teaching the patient what to
expect at the rehabilitation facility will not maximize the patients rehabilitation potential. B.
Keeping the patient on bedrest could cause further mobility issues. D. Turning the patient every
2 hours to prevent ulcer formation and contractures will not necessarily maximize the patients
rehabilitation potential.
The nurse is assisting in preparing a patient for transfer to a rehabilitation facility after a stroke. What
should the nurse explain as the goal for rehabilitation?
a. To monitor neurological status
b. To cure any effects of the stroke
c. To maximize remaining abilities
d. To determine the extent of neurological deficits
c. To maximize remaining abilities
Rehabilitation can help the patient maximize remaining abilities. A. D. At this point, the patients
neurological status should be stable, and all the diagnostic work has been completed. B. Cure is
not realistic.
A patient is admitted to the hospital with a severe headache and photophobia. A lumbar puncture
confirms a bleeding aneurysm. What nursing interventions should the nurse anticipate assisting with
to prevent increased intracranial pressure (ICP) during the acute phase of illness?
a. Morphine, dark glasses, and expectorants
b. Quiet room, head of bed up, and stool softeners
c. Coughing and deep breathing exercises and tranquilizers
d. Range of motion exercises, bedside commode, and suctioning as needed
b. Quiet room, head of bed up, and stool softeners
A quiet room with minimal stressors, elevated head, and stool softeners can help reduce ICP. A.
, C. Morphine and tranquilizers are not usually recommended because they can make
neurological assessment difficult. A. C. Expectorants can promote coughing, which can raise ICP.
C. D. Exercises, moving, and suctioning can also raise ICP.
A client with a subarachnoid bleed refuses to use a bedpan and becomes angry when denied
permission to walk to the bathroom. While waiting to hear from the health care provider (HCP), which
action should the nurse take?
a. Help the patient to get up on a bedside commode
b. Wait for the neurosurgeon to call back with orders
c. Page security to restrain the patient from harming the nurse
d. Administer an as-needed dose of a sedative that is ordered
d. Administer an as-needed dose of a sedative that is ordered
Patients with subarachnoid hemorrhage are at risk for rebleeding. A. Straining to have a bowel
movement and agitation both increase the risk of rebleeding. B. The patient may need to be
sedated until the physician can be contacted. C. Bringing in security will be upsetting to the
patient and can also increase the risk of raising the BP and bleeding.
A patient is experiencing bilateral hemiparesis, dysphasia, visual changes, and altered level of
consciousness, ataxia, and dysphagia. Which artery was most likely affected in this patients stroke?
a. Carotid
b. Middle cerebral
c. Posterior cerebral
d. Vertebrobasilar/cerebellar
d. Vertebrobasilar/cerebellar
These are symptoms of vertebrobasilar/cerebellar occlusion. A. B. C. Carotid and middle or
posterior cerebral occlusions are not associated with ataxia or dysphagia.
The patient is diagnosed with a cerebral vascular accident that has the slowest rate of recovery and
the highest probability of causing extensive neurological deficits. For which type of stroke should the
nurse plan care for this patient?
a. Thrombotic stroke
b. Cerebral aneurysm
c. Subarachnoid hemorrhage (SAH)
d. Reversible ischemic neurological deficit (RIND)
c. Subarachnoid hemorrhage (SAH)
SAH is caused by rupture of blood vessels on the surface of the brain. This type of infarct has the
slowest rate of recovery and the highest probability of leaving the patient with extensive
Adults / Edition 2 2025 Brand New!!!
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
c. Left hemisphere
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 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
c. Expressive aphasia
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.
The nurse is documenting care provided to a patient with left-sided flaccidity caused by a stroke.
Which term should the nurse use to document this patients motor status?
a. Ipsilateral paraplegia
b. Ipsilateral hemiparesis
c. Contralateral hemiplegia
d. Contralateral quadriparesis
, c. Contralateral hemiplegia
A patient with a stroke has symptoms on the opposite side of the stroke, which is called
contralateral. One-sided flaccidity is called hemiplegia. A. Ipsilateral means the same side. Para
refers to the lower extremities. D. Quad refers to all four extremities; B. Hemiparesis is another
term for hemiplegia.
A patient comes into the emergency department with symptoms of a stroke. Which medication
should the nurse expect may be given to the patient if diagnostic testing confirms an ischemic stroke?
a. Heparin
b. Clopidogrel (Plavix)
c. Warfarin (Coumadin)
d. Tissue-type plasminogen activator (tPA)
d. Tissue-type plasminogen activator (tPA)
tPA is a thrombolytic agent that can break down the thrombus causing the occlusion, which can
potentially prevent or completely reverse the symptoms of an ischemic stroke. A. B. C. Heparin,
warfarin, and clopidogrel can help prevent clots but are not effective in breaking up an existing
clot.
A patient is prescribed an antiplatelet agent to prevent strokes. Which agent was this patient most
likely prescribed?
a. Aspirin
b. Warfarin (Coumadin)
c. Acetaminophen (Tylenol)
d. Tissue-type plasminogen activator (tPA)
Aspirin
Aspirin is a platelet aggregation inhibitor. C. Tylenol is an analgesic but does not affect platelet
function. B. Warfarin is an anticoagulant. D. tPA is a thrombolytic agent.
A patient with symptoms of impending stroke is scheduled to have a cerebral angiogram. Which
statement should the nurse include when assisting with patient teaching?
a. This test is designed to detect vascular lesions in the brain.
b. The angiogram is done to help identify swelling in the brain.
c. We need to do this to evaluate electrical function of the brain.
d. This test is done to examine cerebrospinal fluid for signs of bleeding.
This test is designed to detect vascular lesions in the brain.
A cerebral angiogram may be completed to determine the patency of cerebral vessels and the
status of any collateral circulation. D. A lumbar puncture is done to examine cerebrospinal fluid
, (CSF). B. Edema may be identified by radiography. C. An electroencephalogram (EEG) shows
electrical function.
The nurse is caring for a hospitalized patient who has had a stroke and is waiting to be transferred to a
rehabilitation facility. What nursing action can best maximize the patients rehabilitation potential
while awaiting the transfer?
a. Teach the patient what to expect at the rehabilitation facility.
b. Keep the patient on bedrest to conserve energy for rehabilitation.
c. Call the physical therapist for bedside rehabilitation until the transfer.
d. Turn the patient every 2 hours to prevent pressure ulcers and contractures.
c. Call the physical therapist for bedside rehabilitation until the transfer.
Rehabilitation should begin as soon as the patient is stable. Waiting until the patient is at the
rehabilitation facility to begin therapy wastes valuable time. A. Teaching the patient what to
expect at the rehabilitation facility will not maximize the patients rehabilitation potential. B.
Keeping the patient on bedrest could cause further mobility issues. D. Turning the patient every
2 hours to prevent ulcer formation and contractures will not necessarily maximize the patients
rehabilitation potential.
The nurse is assisting in preparing a patient for transfer to a rehabilitation facility after a stroke. What
should the nurse explain as the goal for rehabilitation?
a. To monitor neurological status
b. To cure any effects of the stroke
c. To maximize remaining abilities
d. To determine the extent of neurological deficits
c. To maximize remaining abilities
Rehabilitation can help the patient maximize remaining abilities. A. D. At this point, the patients
neurological status should be stable, and all the diagnostic work has been completed. B. Cure is
not realistic.
A patient is admitted to the hospital with a severe headache and photophobia. A lumbar puncture
confirms a bleeding aneurysm. What nursing interventions should the nurse anticipate assisting with
to prevent increased intracranial pressure (ICP) during the acute phase of illness?
a. Morphine, dark glasses, and expectorants
b. Quiet room, head of bed up, and stool softeners
c. Coughing and deep breathing exercises and tranquilizers
d. Range of motion exercises, bedside commode, and suctioning as needed
b. Quiet room, head of bed up, and stool softeners
A quiet room with minimal stressors, elevated head, and stool softeners can help reduce ICP. A.
, C. Morphine and tranquilizers are not usually recommended because they can make
neurological assessment difficult. A. C. Expectorants can promote coughing, which can raise ICP.
C. D. Exercises, moving, and suctioning can also raise ICP.
A client with a subarachnoid bleed refuses to use a bedpan and becomes angry when denied
permission to walk to the bathroom. While waiting to hear from the health care provider (HCP), which
action should the nurse take?
a. Help the patient to get up on a bedside commode
b. Wait for the neurosurgeon to call back with orders
c. Page security to restrain the patient from harming the nurse
d. Administer an as-needed dose of a sedative that is ordered
d. Administer an as-needed dose of a sedative that is ordered
Patients with subarachnoid hemorrhage are at risk for rebleeding. A. Straining to have a bowel
movement and agitation both increase the risk of rebleeding. B. The patient may need to be
sedated until the physician can be contacted. C. Bringing in security will be upsetting to the
patient and can also increase the risk of raising the BP and bleeding.
A patient is experiencing bilateral hemiparesis, dysphasia, visual changes, and altered level of
consciousness, ataxia, and dysphagia. Which artery was most likely affected in this patients stroke?
a. Carotid
b. Middle cerebral
c. Posterior cerebral
d. Vertebrobasilar/cerebellar
d. Vertebrobasilar/cerebellar
These are symptoms of vertebrobasilar/cerebellar occlusion. A. B. C. Carotid and middle or
posterior cerebral occlusions are not associated with ataxia or dysphagia.
The patient is diagnosed with a cerebral vascular accident that has the slowest rate of recovery and
the highest probability of causing extensive neurological deficits. For which type of stroke should the
nurse plan care for this patient?
a. Thrombotic stroke
b. Cerebral aneurysm
c. Subarachnoid hemorrhage (SAH)
d. Reversible ischemic neurological deficit (RIND)
c. Subarachnoid hemorrhage (SAH)
SAH is caused by rupture of blood vessels on the surface of the brain. This type of infarct has the
slowest rate of recovery and the highest probability of leaving the patient with extensive
