1. A nurse is teaching a family about stroke mechanisms. Which statements
are accurate? Select all that apply.
A. A thrombotic stroke develops from plaque within a cerebral artery.
B. An embolic stroke forms locally in the brain after head trauma.
C. An embolic stroke is caused by a clot that travels to the brain.
D. A hemorrhagic stroke results from a ruptured cerebral vessel.
E. A thrombotic stroke is most often caused by an aneurysm rupture.
ANS: A, C, D
Rationale:
A (Correct): Thrombotic = in-situ clot formation, often
atherosclerotic plaque in cerebral arteries.
C (Correct): Embolic = clot travels from elsewhere (e.g., heart) and
lodges in cerebral circulation.
D (Correct): Hemorrhagic = bleeding due to vessel rupture.
B (Incorrect): Describes local clot; embolic travels. Could be correct
if the stem said “thrombotic.”
E (Incorrect): Aneurysm rupture causes hemorrhagic, not
thrombotic, stroke; could be correct if asking about hemorrhagic
etiologies.
2. A client with severe headache and sudden neuro deficit arrives to the ED.
Which diagnostic action should the nurse anticipate first?
A. CT head with IV contrast
B. CT head without contrast
C. MRI brain with gadolinium
D. Cerebral angiography
ANS: B
Rationale:
B (Correct): Non-contrast CT first—rapidly detects acute blood and
guides next steps.
A (Incorrect): Contrast can obscure acute blood and is avoided
initially; can follow a clear non-contrast CT.
, C (Incorrect): MRI is sensitive but takes longer; not first in acute
suspected bleed.
D (Incorrect): Angio evaluates vessels/interventions later; not first-
line in the crashing patient.
3. Which ED triage note requires the most immediate stroke risk
counseling?
A. 58-year-old with controlled HTN on meds
B. 52-year-old with uncontrolled hypertension
C. 60-year-old with migraines
D. 63-year-old with hyperlipidemia on statin
ANS: B
Rationale:
B (Correct): Uncontrolled HTN is a major precipitant of vessel
rupture → hemorrhagic stroke.
A (Incorrect): Controlled HTN still a risk, but urgency is lower.
C (Incorrect): Migraine ≠ primary hemorrhagic risk.
D (Incorrect): Lipids relate more to ischemic atherosclerosis than to
acute hemorrhage risk.
4. A client’s GCS drops from 14 to 12 over 30 minutes. What is the priority
action?
A. Reassess in 1 hour
B. Document and continue routine care
C. Notify the provider now
D. Administer PRN analgesic
ANS: C
Rationale:
C (Correct): A ≥2-point decrease is clinically significant and must
be reported promptly.
A (Incorrect): Delay risks missing deterioration.
B (Incorrect): Documentation alone is insufficient.
, D (Incorrect): Pain control may be needed, but neuro change takes
priority.
5. Which GCS combination reflects moderate disability?
A. E4 V5 M6
B. E3 V3 M4
C. E1 V1 M1
D. E2 V2 M2
ANS: B
Rationale:
B (Correct): Total = 10 → moderate disability (9–12).
A (Incorrect): Total 15 = normal/mild (13–15).
C (Incorrect): Total 3 = lowest possible, severe coma.
D (Incorrect): Total 6 = severe (3–8).
6. Which assessment findings most directly indicate dysfunction of CN III,
IV, or VI? Select all that apply.
A. Nystagmus
B. Dysconjugate gaze
C. Ocular palsy in one eye
D. Loss of corneal reflex
E. Pupillary dilation unreactive to light
ANS: A, B, C, E
Rationale:
A/B/C (Correct): Extraocular muscle control (III, IV, VI) →
nystagmus, dysconjugate gaze, ocular palsy.
E (Correct): CN III controls pupillary constrictor fibers; dysfunction
→ dilated, sluggish/absent light response.
D (Incorrect): Corneal reflex is CN V (sensory) and CN VII
(motor); could be correct if the question targeted V/VII.
, 7. Which statement from a client with facial pain shows understanding of
trigeminal neuralgia?
A. “It’s due to a viral infection of my facial nerve.”
B. “It’s often caused by vascular compression of my trigeminal nerve.”
C. “It means I will lose vision in my eye.”
D. “It’s a problem with my spinal nerves.”
ANS: B
Rationale:
B (Correct): CN V irritation from adjacent vessels → paroxysmal
facial pain.
A (Incorrect): Viral paresis fits Bell palsy (CN VII) more than TN.
C (Incorrect): Vision loss is not typical of TN.
D (Incorrect): TN is a cranial nerve disorder.
8. A driver sustains a rapid deceleration injury hitting a wall; CT shows
frontal and occipital contusions. What pattern is this?
A. Focal (coup)
B. Diffuse axonal injury
C. Coup-contrecoup (polar)
D. Basilar skull fracture
ANS: C
Rationale:
C (Correct): Acceleration–deceleration with injuries front and back
= coup-contrecoup (polar).
A (Incorrect): Focal/coup = single site at impact only.
B (Incorrect): DAI = widespread axonal injury; not just two poles.
D (Incorrect): A bone injury with signs like CSF leak; not just
parenchymal contusions.
9. Which ED vital-sign pattern most suggests Cushing reflex in acute brain
ischemia?
A. ↓BP, ↑HR, regular respirations
are accurate? Select all that apply.
A. A thrombotic stroke develops from plaque within a cerebral artery.
B. An embolic stroke forms locally in the brain after head trauma.
C. An embolic stroke is caused by a clot that travels to the brain.
D. A hemorrhagic stroke results from a ruptured cerebral vessel.
E. A thrombotic stroke is most often caused by an aneurysm rupture.
ANS: A, C, D
Rationale:
A (Correct): Thrombotic = in-situ clot formation, often
atherosclerotic plaque in cerebral arteries.
C (Correct): Embolic = clot travels from elsewhere (e.g., heart) and
lodges in cerebral circulation.
D (Correct): Hemorrhagic = bleeding due to vessel rupture.
B (Incorrect): Describes local clot; embolic travels. Could be correct
if the stem said “thrombotic.”
E (Incorrect): Aneurysm rupture causes hemorrhagic, not
thrombotic, stroke; could be correct if asking about hemorrhagic
etiologies.
2. A client with severe headache and sudden neuro deficit arrives to the ED.
Which diagnostic action should the nurse anticipate first?
A. CT head with IV contrast
B. CT head without contrast
C. MRI brain with gadolinium
D. Cerebral angiography
ANS: B
Rationale:
B (Correct): Non-contrast CT first—rapidly detects acute blood and
guides next steps.
A (Incorrect): Contrast can obscure acute blood and is avoided
initially; can follow a clear non-contrast CT.
, C (Incorrect): MRI is sensitive but takes longer; not first in acute
suspected bleed.
D (Incorrect): Angio evaluates vessels/interventions later; not first-
line in the crashing patient.
3. Which ED triage note requires the most immediate stroke risk
counseling?
A. 58-year-old with controlled HTN on meds
B. 52-year-old with uncontrolled hypertension
C. 60-year-old with migraines
D. 63-year-old with hyperlipidemia on statin
ANS: B
Rationale:
B (Correct): Uncontrolled HTN is a major precipitant of vessel
rupture → hemorrhagic stroke.
A (Incorrect): Controlled HTN still a risk, but urgency is lower.
C (Incorrect): Migraine ≠ primary hemorrhagic risk.
D (Incorrect): Lipids relate more to ischemic atherosclerosis than to
acute hemorrhage risk.
4. A client’s GCS drops from 14 to 12 over 30 minutes. What is the priority
action?
A. Reassess in 1 hour
B. Document and continue routine care
C. Notify the provider now
D. Administer PRN analgesic
ANS: C
Rationale:
C (Correct): A ≥2-point decrease is clinically significant and must
be reported promptly.
A (Incorrect): Delay risks missing deterioration.
B (Incorrect): Documentation alone is insufficient.
, D (Incorrect): Pain control may be needed, but neuro change takes
priority.
5. Which GCS combination reflects moderate disability?
A. E4 V5 M6
B. E3 V3 M4
C. E1 V1 M1
D. E2 V2 M2
ANS: B
Rationale:
B (Correct): Total = 10 → moderate disability (9–12).
A (Incorrect): Total 15 = normal/mild (13–15).
C (Incorrect): Total 3 = lowest possible, severe coma.
D (Incorrect): Total 6 = severe (3–8).
6. Which assessment findings most directly indicate dysfunction of CN III,
IV, or VI? Select all that apply.
A. Nystagmus
B. Dysconjugate gaze
C. Ocular palsy in one eye
D. Loss of corneal reflex
E. Pupillary dilation unreactive to light
ANS: A, B, C, E
Rationale:
A/B/C (Correct): Extraocular muscle control (III, IV, VI) →
nystagmus, dysconjugate gaze, ocular palsy.
E (Correct): CN III controls pupillary constrictor fibers; dysfunction
→ dilated, sluggish/absent light response.
D (Incorrect): Corneal reflex is CN V (sensory) and CN VII
(motor); could be correct if the question targeted V/VII.
, 7. Which statement from a client with facial pain shows understanding of
trigeminal neuralgia?
A. “It’s due to a viral infection of my facial nerve.”
B. “It’s often caused by vascular compression of my trigeminal nerve.”
C. “It means I will lose vision in my eye.”
D. “It’s a problem with my spinal nerves.”
ANS: B
Rationale:
B (Correct): CN V irritation from adjacent vessels → paroxysmal
facial pain.
A (Incorrect): Viral paresis fits Bell palsy (CN VII) more than TN.
C (Incorrect): Vision loss is not typical of TN.
D (Incorrect): TN is a cranial nerve disorder.
8. A driver sustains a rapid deceleration injury hitting a wall; CT shows
frontal and occipital contusions. What pattern is this?
A. Focal (coup)
B. Diffuse axonal injury
C. Coup-contrecoup (polar)
D. Basilar skull fracture
ANS: C
Rationale:
C (Correct): Acceleration–deceleration with injuries front and back
= coup-contrecoup (polar).
A (Incorrect): Focal/coup = single site at impact only.
B (Incorrect): DAI = widespread axonal injury; not just two poles.
D (Incorrect): A bone injury with signs like CSF leak; not just
parenchymal contusions.
9. Which ED vital-sign pattern most suggests Cushing reflex in acute brain
ischemia?
A. ↓BP, ↑HR, regular respirations
