EXAM WITH 100% CORRECT
ANSWERS 2025/2026
An ER nurse is completing an assessment on a patient that is alert
but struggles to answer questions. When she attempts to talk, she
slurs her speech and appears very frightened. What additional
clinical manifestation does the nurse expect to find if nacy's
sysmptoms have been caused by a brain attack (stroke)?
A. A carotid bruit
B. A hypotensive blood pressure
C. hyperreflexic deep tendon relexes.
D. Decreased bowel sounds correct answers >> A) A carotid
bruit.
Rationale: the carotid artery (artery to the brain) is narrowed in
clients with a brain attack. A bruit is an abnormal sound heard on
auscultation resulting from interference with normal blood flow.
Usually the blood pressure is hypertensive. Initially flaccid
paralysis occurs, resulting in hyporefkexic deep tendon reflexes.
Bowel sounds are not indicative of a brain attack.
Which clinical manifestation further supports an assessment of a
left-sided brain attack?
,A) Visual field deficit on the left side.
B) Spatial-perceptual deficits.
C) Paresthesia of the left side.
D) Global aphasia.
D) Global aphasia. correct answers >> D) Global aphasia.
Rationale: Global aphasia refers to difficulty speaking, listening,
and understanding, as well as difficulty reading and writing.
Symptoms vary from person to person. Aphasia may occur
secondary to any brain injury involving the left hemisphere. Visual
field deficits, spatial-perceptual deficits, and paresthsia of the left
side usually occur with right-sided brain attack.
When preparing a patient for a noncontrast computed
tomography (CT) scan STAT, what nursing intervention should the
nurse implement?
A) Determine if the client has any allergies to iodine
B) Explain that the client will not be able to move her head
throughout the CT scan.
C) Premedicate the client to decrease pain prior to having the
procedure.
D) Provide an explanation of relaxation exercises prior to the
procedure. correct answers >> B) Explain that the client will
not be able to move her head throughout the CT scan.
Rationale: Because head motion will distort the images, Nancy
will have to remain still throughout the procedure. Allergies to
iodine is important if contrast dye is being used for the CT scan.
Premedicating the client to decrease pain prior to the procedure
,is unnecessary because CT scanning is a noninvasive and painless
procedure. Providing an explanation of relaxation exercises prior
to the procedure is a worthwhile intervention to decrease anxiety
but is not of highest priority.
A neurologist prescribes a magnetic resonance imaging (MRI) of
the head STAT for a patient. Which data warrants immediate
intervention by the nurse concerning this diagnostic test?
A) Elevated blood pressure.
B) Allergy to shell fish.
C) Right hip replacement.
D) History of atrial fibrillation. correct answers >> C) Right
hip replacement.
The magnetic field generated by the MRI is so strong that metal-
containing items are strongly attracted to the magnet. Because
the hip joint is made of metal, a lead shield must be used during
the procedure. Elevated blood pressure, an allergy to shell fish,
and a history of atrial fibrillation would not affect the MRI.
A client's daughter is sitting by her mother's bedside who was
recently transferred to the Intermediate Care Unit. She states "I
don't understand what a brain attack is. The healthcare provider
told me my mother is in serious condition and they are going to
run several tests. I just don't know what is going on. What
happened to my mother?" What is the best response by the
nurse?
, A) "I am sorry, but according to the Health Insurance Portability
and Accounting Act (HIPAA), I cannot give you any information."
B) "Your mother has had a stroke, and the blood supply to the
brain has been blocked."
C) "How do you feel about what the healthcare provider said?"
D) "I will call the healthcare provider so he/she can talk to you
about your mother's serious condition." correct answers >>
B) "Your mother has had a stroke, and the blood supply to the
brain has been blocked."
Rationale: The nurse can discuss what a diagnosis means. Nancy
is unable to make decisions, so the next of kin, her daughter, Gail,
needs sufficient information to make informed decisions. The
nurse has the knowledge, and the responsibility, to explain
Nancy's condition to Gail. The nurse should give facts first, and
then address her feelings after the information is provided.
What is the normal range for cardiac output? correct answers
>> The normal range for cardiac output to ensure cerebral
blood flow and oxygen delivery is 4 to 8 L/min.
A client was admitted with the diagnosis of a brain attack. Their
symptoms began 24 hours before being admitted. Why would this
client not be a candidate for for thrombolytic therapy? correct
answers >> Thrombolytic therapy is contraindicated in clients
with symptom onset longer than 3 hours prior to admission. This
client had symptoms for 24 hours before being brought to the
medical center
What are plate guards? correct answers >> Plate guards
prevent food from being pushed off the plate. Using plate guards