NUR-211 TEST 2 QUESTIONS
WITH CORRECT ANSWERS
A client is in the emergency department reporting a brief episode
during which he was dizzy, unable to speak, and felt like his legs were
very heavy. Currently the client's neurologic examination is normal.
About what drug should the nurse plan to teach the client?
a. Alteplase (Activase)
b. Clopidogrel (Plavix)
c. Heparin sodium
d. Mannitol (Osmitrol) -- Correct Answer ✔✔ B
This client's manifestations are consistent with a transient ischemic
attack, and the client would be prescribed aspirin or clopidogrel on
discharge. Alteplase is used for ischemic stroke. Heparin and mannitol
are not used for this condition.
A client had an embolic stroke and is having an echocardiogram. When
the client asks why the provider ordered "a test on my heart," how
should the nurse respond?
a. "Most of these types of blood clots come from the heart."
b. "Some of the blood clots may have gone to your heart too."
c. "We need to see if your heart is strong enough for therapy."
,d. "Your heart may have been damaged in the stroke too." -- Correct
Answer ✔✔ A
An embolic stroke is caused when blood clots travel from one area of
the body to the brain. The most common source of the clots is the
heart. The other statements are inaccurate.
A nurse receives a report on a client who had a left-sided stroke and
has homonymous hemianopsia. What action by the nurse is most
appropriate for this client?
a. Assess for bladder retention and/or incontinence.
b. Listen to the client's lungs after eating or drinking.
c. Prop the client's right side up when sitting in a chair.
d. Rotate the client's meal tray when the client stops eating. -- Correct
Answer ✔✔ D
This condition is blindness on the same side of both eyes. The client
must turn his or her head to see the entire visual field. The client may
not see all the food on the tray, so the nurse rotates it so uneaten food
is now within the visual field. This condition is not related to bladder
function, difficulty swallowing, or lack of trunk control.
A client with a stroke is being evaluated for fibrinolytic therapy. What
information from the client or family is most important for the nurse to
obtain?
a. Loss of bladder control
b. Other medical conditions
c. Progression of symptoms
d. Time of symptom onset -- Correct Answer ✔✔ D
,The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5
hours, so the exact time of symptom onset is the most important
information for this client. The other information is not as critical.
A client is being prepared for a mechanical embolectomy. What action
by the nurse takes priority?
a. Assess for contraindications to fibrinolytics.
b. Ensure that informed consent is on the chart.
c. Perform a full neurologic assessment.
d. Review the client's medication lists. -- Correct Answer ✔✔ B
For this invasive procedure, the client needs to give informed consent.
The nurse ensures that this is on the chart prior to the procedure
beginning. Fibrinolytics are not used. A neurologic assessment and
medication review are important, but the consent is the priority.
A client had an embolectomy for an arteriovenous malformation (AVM).
The client is now reporting a severe headache and has vomited. What
action by the nurse takes priority?
a. Administer pain medication.
b. Assess the client's vital signs.
c. Notify the Rapid Response Team.
d. Raise the head of the bed. -- Correct Answer ✔✔ C
This client may be experiencing a rebleed from the AVM. The most
important action is to call the Rapid Response Team as this is an
emergency. The nurse can assess vital signs while someone else
notifies the Team, but getting immediate medical attention is the
priority. Administering pain medication may not be warranted if the
, client must return to surgery. The optimal position for the client with
an AVM has not been determined, but calling the Rapid Response
Team takes priority over positioning.
A student nurse is preparing morning medications for a client who had
a stroke. The student plans to hold the docusate sodium (Colace)
because the client had a large stool earlier. What action by the
supervising nurse is best?
a. Have the student ask the client if it is desired or not.
b. Inform the student that the docusate should be given.
c. Tell the student to document the rationale.
d. Tell the student to give it unless the client refuses. -- Correct Answer
✔✔ B
Stool softeners should be given to clients with neurologic disorders in
order to prevent an elevation in intracranial pressure that accompanies
the Valsalva maneuver when constipated. The supervising nurse
should instruct the student to administer the docusate. The other
options are not appropriate. The medication could be held for diarrhea.
A client experiences impaired swallowing after a stroke and has
worked with speech-language pathology on eating. What nursing
assessment best indicates that a priority goal for this problem has
been met?
a. Chooses preferred items from the menu
b. Eats 75% to 100% of all meals and snacks
c. Has clear lung sounds on auscultation
d. Gains 2 pounds after 1 week -- Correct Answer ✔✔ C
WITH CORRECT ANSWERS
A client is in the emergency department reporting a brief episode
during which he was dizzy, unable to speak, and felt like his legs were
very heavy. Currently the client's neurologic examination is normal.
About what drug should the nurse plan to teach the client?
a. Alteplase (Activase)
b. Clopidogrel (Plavix)
c. Heparin sodium
d. Mannitol (Osmitrol) -- Correct Answer ✔✔ B
This client's manifestations are consistent with a transient ischemic
attack, and the client would be prescribed aspirin or clopidogrel on
discharge. Alteplase is used for ischemic stroke. Heparin and mannitol
are not used for this condition.
A client had an embolic stroke and is having an echocardiogram. When
the client asks why the provider ordered "a test on my heart," how
should the nurse respond?
a. "Most of these types of blood clots come from the heart."
b. "Some of the blood clots may have gone to your heart too."
c. "We need to see if your heart is strong enough for therapy."
,d. "Your heart may have been damaged in the stroke too." -- Correct
Answer ✔✔ A
An embolic stroke is caused when blood clots travel from one area of
the body to the brain. The most common source of the clots is the
heart. The other statements are inaccurate.
A nurse receives a report on a client who had a left-sided stroke and
has homonymous hemianopsia. What action by the nurse is most
appropriate for this client?
a. Assess for bladder retention and/or incontinence.
b. Listen to the client's lungs after eating or drinking.
c. Prop the client's right side up when sitting in a chair.
d. Rotate the client's meal tray when the client stops eating. -- Correct
Answer ✔✔ D
This condition is blindness on the same side of both eyes. The client
must turn his or her head to see the entire visual field. The client may
not see all the food on the tray, so the nurse rotates it so uneaten food
is now within the visual field. This condition is not related to bladder
function, difficulty swallowing, or lack of trunk control.
A client with a stroke is being evaluated for fibrinolytic therapy. What
information from the client or family is most important for the nurse to
obtain?
a. Loss of bladder control
b. Other medical conditions
c. Progression of symptoms
d. Time of symptom onset -- Correct Answer ✔✔ D
,The time limit for initiating fibrinolytic therapy for a stroke is 3 to 4.5
hours, so the exact time of symptom onset is the most important
information for this client. The other information is not as critical.
A client is being prepared for a mechanical embolectomy. What action
by the nurse takes priority?
a. Assess for contraindications to fibrinolytics.
b. Ensure that informed consent is on the chart.
c. Perform a full neurologic assessment.
d. Review the client's medication lists. -- Correct Answer ✔✔ B
For this invasive procedure, the client needs to give informed consent.
The nurse ensures that this is on the chart prior to the procedure
beginning. Fibrinolytics are not used. A neurologic assessment and
medication review are important, but the consent is the priority.
A client had an embolectomy for an arteriovenous malformation (AVM).
The client is now reporting a severe headache and has vomited. What
action by the nurse takes priority?
a. Administer pain medication.
b. Assess the client's vital signs.
c. Notify the Rapid Response Team.
d. Raise the head of the bed. -- Correct Answer ✔✔ C
This client may be experiencing a rebleed from the AVM. The most
important action is to call the Rapid Response Team as this is an
emergency. The nurse can assess vital signs while someone else
notifies the Team, but getting immediate medical attention is the
priority. Administering pain medication may not be warranted if the
, client must return to surgery. The optimal position for the client with
an AVM has not been determined, but calling the Rapid Response
Team takes priority over positioning.
A student nurse is preparing morning medications for a client who had
a stroke. The student plans to hold the docusate sodium (Colace)
because the client had a large stool earlier. What action by the
supervising nurse is best?
a. Have the student ask the client if it is desired or not.
b. Inform the student that the docusate should be given.
c. Tell the student to document the rationale.
d. Tell the student to give it unless the client refuses. -- Correct Answer
✔✔ B
Stool softeners should be given to clients with neurologic disorders in
order to prevent an elevation in intracranial pressure that accompanies
the Valsalva maneuver when constipated. The supervising nurse
should instruct the student to administer the docusate. The other
options are not appropriate. The medication could be held for diarrhea.
A client experiences impaired swallowing after a stroke and has
worked with speech-language pathology on eating. What nursing
assessment best indicates that a priority goal for this problem has
been met?
a. Chooses preferred items from the menu
b. Eats 75% to 100% of all meals and snacks
c. Has clear lung sounds on auscultation
d. Gains 2 pounds after 1 week -- Correct Answer ✔✔ C
