1
"Neuro Disorders NCLEX-RN Practice | Saunders 9th Ed
Chapter 59 | Stroke, ICP, Seizures & NGN 2025-2026 A+
Verified Q&A with Rationales"
1. A client with suspected stroke arrives at the ED. Which initial nursing
actions are appropriate?
Select all that apply:
A. Maintain airway and oxygenation
B. Assess time of symptom onset
C. Administer aspirin immediately
D. Prepare for CT scan
E. Monitor blood pressure closely
Correct Answers: A, B, D, E
Rationale: Initial stroke care involves airway support, identifying the time of onset
, 2
(which determines tPA eligibility), preparing for a head CT to differentiate between
ischemic and hemorrhagic stroke, and monitoring BP. Aspirin is not given until
hemorrhage is ruled out.
2. The nurse is caring for a patient post-stroke with expressive aphasia. What
interventions are helpful?
Select all that apply:
A. Use picture boards
B. Encourage writing
C. Repeat instructions slowly
D. Speak louder
E. Allow time to respond
Correct Answers: A, B, C, E
Rationale: Communication aids like picture boards and written responses support
expressive aphasia. Speaking clearly and slowly, and allowing time for processing,
helps. Speaking louder is ineffective unless the patient also has hearing loss.
3. Which findings in a stroke patient indicate increasing intracranial pressure
(ICP)?
, 3
Select all that apply:
A. Headache and nausea
B. Bradycardia
C. Increased blood pressure
D. Unequal pupils
E. Hyperactive reflexes
Correct Answers: A, B, C, D
Rationale: Classic signs of increased ICP include headache, nausea, bradycardia,
hypertension (Cushing's triad), and changes in pupils. Hyperreflexia is less
specific.
4. A client is diagnosed with a left-sided stroke. Which expected findings will
the nurse likely observe?
Select all that apply:
A. Right-sided weakness
B. Aphasia
C. Impaired logic and math
D. Impulsiveness
E. Cautious behavior
, 4
Correct Answers: A, B, C, E
Rationale: Left brain damage causes right-sided deficits, language issues, and
cautious behavior. Impulsiveness is more common in right-brain strokes.
5. What are priority nursing actions during an active tonic-clonic seizure?
Select all that apply:
A. Turn the patient to the side
B. Restrain the limbs
C. Time the seizure
D. Remove nearby objects
E. Insert oral airway immediately
Correct Answers: A, C, D
Rationale: During a seizure, ensure safety by turning the patient, timing the
episode, and clearing the area. Never restrain or place anything in the mouth during
a seizure.
6. A client with epilepsy is being discharged. What education should the nurse
provide?
"Neuro Disorders NCLEX-RN Practice | Saunders 9th Ed
Chapter 59 | Stroke, ICP, Seizures & NGN 2025-2026 A+
Verified Q&A with Rationales"
1. A client with suspected stroke arrives at the ED. Which initial nursing
actions are appropriate?
Select all that apply:
A. Maintain airway and oxygenation
B. Assess time of symptom onset
C. Administer aspirin immediately
D. Prepare for CT scan
E. Monitor blood pressure closely
Correct Answers: A, B, D, E
Rationale: Initial stroke care involves airway support, identifying the time of onset
, 2
(which determines tPA eligibility), preparing for a head CT to differentiate between
ischemic and hemorrhagic stroke, and monitoring BP. Aspirin is not given until
hemorrhage is ruled out.
2. The nurse is caring for a patient post-stroke with expressive aphasia. What
interventions are helpful?
Select all that apply:
A. Use picture boards
B. Encourage writing
C. Repeat instructions slowly
D. Speak louder
E. Allow time to respond
Correct Answers: A, B, C, E
Rationale: Communication aids like picture boards and written responses support
expressive aphasia. Speaking clearly and slowly, and allowing time for processing,
helps. Speaking louder is ineffective unless the patient also has hearing loss.
3. Which findings in a stroke patient indicate increasing intracranial pressure
(ICP)?
, 3
Select all that apply:
A. Headache and nausea
B. Bradycardia
C. Increased blood pressure
D. Unequal pupils
E. Hyperactive reflexes
Correct Answers: A, B, C, D
Rationale: Classic signs of increased ICP include headache, nausea, bradycardia,
hypertension (Cushing's triad), and changes in pupils. Hyperreflexia is less
specific.
4. A client is diagnosed with a left-sided stroke. Which expected findings will
the nurse likely observe?
Select all that apply:
A. Right-sided weakness
B. Aphasia
C. Impaired logic and math
D. Impulsiveness
E. Cautious behavior
, 4
Correct Answers: A, B, C, E
Rationale: Left brain damage causes right-sided deficits, language issues, and
cautious behavior. Impulsiveness is more common in right-brain strokes.
5. What are priority nursing actions during an active tonic-clonic seizure?
Select all that apply:
A. Turn the patient to the side
B. Restrain the limbs
C. Time the seizure
D. Remove nearby objects
E. Insert oral airway immediately
Correct Answers: A, C, D
Rationale: During a seizure, ensure safety by turning the patient, timing the
episode, and clearing the area. Never restrain or place anything in the mouth during
a seizure.
6. A client with epilepsy is being discharged. What education should the nurse
provide?
