STROKE- NCLEX|123 Verified Questions
With Correct Answers.,.
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 - AnswerDifficulty swallowing
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. - AnswerShe is taking coumadin.
,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 - AnswerHomonymous hemianopsia
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. - AnswerPerform a vision field assessment.
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 - AnswerTransient ischemic attack
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 - AnswerAgnosia
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."
b) "Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity,
and trouble swallowing."
c) "Clinical manifestations of a stroke depend on how q - Answer"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."
Clinical manifestations following a stroke are highly variable and depend on the area of
the cerebral cortex and the affected hemisphere, the degree of blockage (total, partial),
, and the presence or absence of adequate collateral circulation. (Collateral circulation is
circulation formed by smaller blood vessels branching off from or near larger occluded
vessels.) Clinical manifestations of a stroke do not depend on the cardiovascular health
of the client or how quickly the clot can be dissolved. Clinical manifestations of a stroke
are not "general" but individual.
When communicating with a client who has sensory (receptive) aphasia, the nurse
should:
a) speak loudly and articulate clearly.
b) allow time for the client to respond.
c) give the client a writing pad.
d) use short, simple sentences. - Answeruse short, simple sentences.
Although sensory aphasia allows the client to hear words, it impairs the ability to
comprehend their meaning. The nurse should use short, simple sentences to promote
comprehension. Allowing time for the client to respond might be helpful but is less
important than simplifying the communication. Because the client's hearing isn't
affected, speaking loudly isn't necessary. A writing pad is helpful for clients with
expressive, not receptive, aphasia.
The nurse is providing information about strokes to a community group. Which of the
following would the nurse identify as the primary initial symptoms of an ischemic stroke?
a) Footdrop and external hip rotation
b) Vomiting and seizures
c) Severe headache and early change in level of consciousness
d) Weakness on one side of the body and difficulty with speech - AnswerWeakness
on one side of the body and difficulty with speech
The main presenting symptoms for an ischemic stroke are numbness or weakness of
the face, arm, or leg, especially on one side of the body; confusion or change in mental
status; and trouble speaking or understanding speech. Severe headache, vomiting,
early change in level of consciousness, and seizures are early signs of a hemorrhagic
stroke. Footdrop and external hip rotation are things that can occur if a stroke victim is
not turned or positioned correctly.
Which of the following insults or abnormalities can cause an ischemic stroke?
With Correct Answers.,.
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 - AnswerDifficulty swallowing
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. - AnswerShe is taking coumadin.
,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 - AnswerHomonymous hemianopsia
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. - AnswerPerform a vision field assessment.
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 - AnswerTransient ischemic attack
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 - AnswerAgnosia
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."
b) "Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity,
and trouble swallowing."
c) "Clinical manifestations of a stroke depend on how q - Answer"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."
Clinical manifestations following a stroke are highly variable and depend on the area of
the cerebral cortex and the affected hemisphere, the degree of blockage (total, partial),
, and the presence or absence of adequate collateral circulation. (Collateral circulation is
circulation formed by smaller blood vessels branching off from or near larger occluded
vessels.) Clinical manifestations of a stroke do not depend on the cardiovascular health
of the client or how quickly the clot can be dissolved. Clinical manifestations of a stroke
are not "general" but individual.
When communicating with a client who has sensory (receptive) aphasia, the nurse
should:
a) speak loudly and articulate clearly.
b) allow time for the client to respond.
c) give the client a writing pad.
d) use short, simple sentences. - Answeruse short, simple sentences.
Although sensory aphasia allows the client to hear words, it impairs the ability to
comprehend their meaning. The nurse should use short, simple sentences to promote
comprehension. Allowing time for the client to respond might be helpful but is less
important than simplifying the communication. Because the client's hearing isn't
affected, speaking loudly isn't necessary. A writing pad is helpful for clients with
expressive, not receptive, aphasia.
The nurse is providing information about strokes to a community group. Which of the
following would the nurse identify as the primary initial symptoms of an ischemic stroke?
a) Footdrop and external hip rotation
b) Vomiting and seizures
c) Severe headache and early change in level of consciousness
d) Weakness on one side of the body and difficulty with speech - AnswerWeakness
on one side of the body and difficulty with speech
The main presenting symptoms for an ischemic stroke are numbness or weakness of
the face, arm, or leg, especially on one side of the body; confusion or change in mental
status; and trouble speaking or understanding speech. Severe headache, vomiting,
early change in level of consciousness, and seizures are early signs of a hemorrhagic
stroke. Footdrop and external hip rotation are things that can occur if a stroke victim is
not turned or positioned correctly.
Which of the following insults or abnormalities can cause an ischemic stroke?
