MEDICAL SURGICAL NURSING SAMPLE QUESTIONNAIRE REVIEWER
NEUROLOGICAL DISORDERS admitted to the emergency
department with sudden
1. A 68-year-old male patient onset right-sided weakness,
who had a left-sided stroke is facial droop, and difficulty
admitted to the hospital. The speaking. Which nursing
patient has right-sided intervention is the highest
weakness and is unable to priority in the initial
perform activities of daily management of this client?
living without assistance. The
nurse is providing oral A. Prepare to administer
hygiene to the patient and is recombinant tissue plasminogen
preparing to use a padded activator (rt-PA).
tongue blade to open the
patient’s mouth. Which B. Discuss the precipitating factors
nursing measure is that caused the symptoms.
inappropriate when C. Schedule for A STAT computer
providing oral hygiene to the tomography (CT) scan of the head.
patient who had a stroke?
D. Notify the speech pathologist for
A. Placing the client on the back an emergency consultation.
with a small pillow under the head.
A CT scan will determine if the
B. Keeping portable suctioning client is having a stroke or has
equipment at the bedside. a brain tumor or another
C. Opening the client’s mouth with neurological disorder. This
a padded tongue blade. would also determine if it is a
hemorrhagic or ischemic
D. Cleaning the client’s mouth and accident and guide the
teeth with a toothbrush. treatment because only an
ischemic stroke can use rt-PA.
A helpless client should be Demonstrates structural
positioned on the side, not on abnormalities, edema,
the back. This lateral position hematomas, ischemia, and
helps secretions escape from infarctions. Demonstrates
the throat and mouth, structural abnormalities,
minimizing the risk of edema, hematomas, ischemia,
aspiration. Observe the patient and infarctions.
for paroxysms of coughing,
food dribbling out or pooling in 3. A client arrives in the
one side of the mouth, food emergency department with
retained for long periods in the an ischemic stroke and
mouth, or nasal regurgitation receives tissue plasminogen
when swallowing liquids. activator (t-PA)
administration. Which is the
2. A 64-year-old client with a priority nursing assessment?
history of hypertension is
MEDICAL SURGICAL NURSING SAMPLE QUESTIONNAIRE REVIEWER
, MEDICAL SURGICAL NURSING SAMPLE QUESTIONNAIRE REVIEWER
A. Time of onset of current stroke Other vital signs are monitored,
but the priority is blood
B. Complete physical and history pressure.
C. Current medications 5. What is a priority nursing
D. Upcoming surgical procedures assessment in the first 24
hours after admission of the
The time of onset of a stroke to client with a thrombotic
t-PA administration is critical. stroke?
Administration within 3 hours
has better outcomes. Tissue A. Cholesterol level
plasminogen activator (tPA) is B. Pupil size and pupillary response
classified as a serine protease
(enzymes that cleave peptide C. Bowel sounds
bonds in proteins). It is thus
one of the essential components D. Echocardiogram
of the dissolution of blood clots. It is crucial to monitor the
Its primary function includes pupil size and pupillary
catalyzing the conversion of response to indicate changes
plasminogen to plasmin, the around the cranial nerves.
primary enzyme involved in Pupil reactions are regulated
dissolving blood clots. by the oculomotor (III) cranial
4. During the first 24 hours nerve and are useful in
after thrombolytic therapy determining whether the brain
for ischemic stroke, the stem is intact. Pupil size and
primary goal is to control the equality is determined by a
client’s: balance between
parasympathetic and
A. Pulse sympathetic innervation.
Response to light reflects the
B. Respirations combined function of the optic
C. Blood pressure (II) and oculomotor (III)
cranial nerves.
D. Temperature
6. What is the expected outcome
Controlling the blood pressure of thrombolytic drug therapy?
is critical because an
intracerebral hemorrhage is A. Increased vascular permeability
the major adverse effect of B. Vasoconstriction
thrombolytic therapy. Blood
pressure should be maintained C. Dissolved emboli
according to the physician and
is specific to the client’s D. Prevention of hemorrhage
ischemic tissue needs and risks Thrombolytic therapy is used to
of bleeding from treatment. dissolve emboli and reestablish
MEDICAL SURGICAL NURSING SAMPLE QUESTIONNAIRE REVIEWER
, MEDICAL SURGICAL NURSING SAMPLE QUESTIONNAIRE REVIEWER
cerebral perfusion. C. An 84-year-old Japanese female.
Thrombolytic treatment is also
known as fibrinolytic or D. A 55-year-old African American
thrombolysis, to dissolve male.
dangerous intravascular clots African Americans have twice
to prevent ischemic damage by the rate of CVAs as Caucasians;
improving blood flow. males are more likely to have
Thrombosis is a significant strokes than females except in
physiological response that advanced years. Of all the risk
limits hemorrhage caused by factors, hypertension is the
large or tiny vascular injury. most common modifiable risk
7. The client diagnosed with factor for stroke. Hypertension
atrial fibrillation has is most prevalent in African-
experienced a transient Americans and also occurs
ischemic attack (TIA). Which earlier in life.
medication would the nurse 9. Which assessment data would
anticipate being ordered for indicate to the nurse that the
the client on discharge? client would be at risk for a
A. A thrombolytic medication hemorrhagic stroke?
B. A beta-blocker medication A. A blood glucose level of 480
mg/dl.
C. An anti-hyperuricemic
medication B. A right-sided carotid bruit.
D. An oral anticoagulant medication C. A blood pressure of 220/120
mmHg.
Thrombi form secondary to
atrial fibrillation. Therefore, an D. The presence of bronchogenic
anticoagulant would be carcinoma.
anticipated to prevent thrombus Uncontrolled hypertension is a
formation; and oral (warfarin risk factor for hemorrhagic
[Coumadin]) at discharge stroke, which is a ruptured
versus intravenous. Oral blood vessel in the cranium.
anticoagulation is indicated for Hypertension is the most
patients with atrial fibrillation common cause of hemorrhagic
or other sources of stroke. Long standing
cardioembolic sources of TIA. hypertension produces
8. Which client would the nurse degeneration of media,
identify as being most at risk breakage of the elastic lamina,
for experiencing a CVA? and fragmentation of smooth
muscles of arteries.
A. A 39-year-old pregnant female.
10. The nurse and unlicensed
B. A 67-year-old Caucasian male. assistive personnel (UAP) are
MEDICAL SURGICAL NURSING SAMPLE QUESTIONNAIRE REVIEWER
, MEDICAL SURGICAL NURSING SAMPLE QUESTIONNAIRE REVIEWER
caring for a client with right- client in which of the
sided paralysis. Which action following circumstances?
by the UAP requires the
nurse to intervene? A. Vomiting continues.
A. The assistant places a gait belt B. Intracranial pressure (ICP) is
around the client’s waist prior to increased.
ambulating. C. The client needs mechanical
B. The assistant places the client on ventilation.
the back with the client’s head to the D. Blood is anticipated in the
side. cerebrospinal fluid (CSF).
C. The assistant places her hand Sudden removal of CSF results
under the client’s right axilla to help in pressures lower in the
him/her move up in bed. lumbar area than the brain and
D. The assistant praises the client favors herniation of the brain;
for attempting to perform ADL’s therefore, LP is contraindicated
independently. with increased ICP. A head
computed tomogram (CT)
This action is inappropriate should be obtained before
and would require intervention performing a lumbar puncture
by the nurse because pulling on if there is a concern for
a flaccid shoulder joint could increased intracranial pressure.
cause shoulder dislocation; as Signs and symptoms of possible
always use a lift sheet for the increased intracranial pressure
client and nurse safety. Avoid include altered mental status,
pulling the affected arm. Place focal neurological deficits,
a hand behind the scapula new-onset seizure, papilledema,
when moving the upper immunocompromised state,
extremity instead of pulling malignancy, history of focal
from the arm; Utilize a lift CNS disease (stroke, focal
sheet during bed repositioning. infection, tumor), concern for
When the patient is sitting mass CNS lesion and age
provide the arm with a firm greater than 60 years old.
support surface
12. A client with a subdural
11. A client admitted to the hematoma becomes restless
hospital with a subarachnoid and confused, with dilation of
hemorrhage has complaints the ipsilateral pupil. The
of severe headache, nuchal physician orders mannitol for
rigidity, and projectile which of the following
vomiting. The nurse knows reasons?
lumbar puncture (LP) would
be contraindicated in this A. To reduce intraocular pressure.
MEDICAL SURGICAL NURSING SAMPLE QUESTIONNAIRE REVIEWER
NEUROLOGICAL DISORDERS admitted to the emergency
department with sudden
1. A 68-year-old male patient onset right-sided weakness,
who had a left-sided stroke is facial droop, and difficulty
admitted to the hospital. The speaking. Which nursing
patient has right-sided intervention is the highest
weakness and is unable to priority in the initial
perform activities of daily management of this client?
living without assistance. The
nurse is providing oral A. Prepare to administer
hygiene to the patient and is recombinant tissue plasminogen
preparing to use a padded activator (rt-PA).
tongue blade to open the
patient’s mouth. Which B. Discuss the precipitating factors
nursing measure is that caused the symptoms.
inappropriate when C. Schedule for A STAT computer
providing oral hygiene to the tomography (CT) scan of the head.
patient who had a stroke?
D. Notify the speech pathologist for
A. Placing the client on the back an emergency consultation.
with a small pillow under the head.
A CT scan will determine if the
B. Keeping portable suctioning client is having a stroke or has
equipment at the bedside. a brain tumor or another
C. Opening the client’s mouth with neurological disorder. This
a padded tongue blade. would also determine if it is a
hemorrhagic or ischemic
D. Cleaning the client’s mouth and accident and guide the
teeth with a toothbrush. treatment because only an
ischemic stroke can use rt-PA.
A helpless client should be Demonstrates structural
positioned on the side, not on abnormalities, edema,
the back. This lateral position hematomas, ischemia, and
helps secretions escape from infarctions. Demonstrates
the throat and mouth, structural abnormalities,
minimizing the risk of edema, hematomas, ischemia,
aspiration. Observe the patient and infarctions.
for paroxysms of coughing,
food dribbling out or pooling in 3. A client arrives in the
one side of the mouth, food emergency department with
retained for long periods in the an ischemic stroke and
mouth, or nasal regurgitation receives tissue plasminogen
when swallowing liquids. activator (t-PA)
administration. Which is the
2. A 64-year-old client with a priority nursing assessment?
history of hypertension is
MEDICAL SURGICAL NURSING SAMPLE QUESTIONNAIRE REVIEWER
, MEDICAL SURGICAL NURSING SAMPLE QUESTIONNAIRE REVIEWER
A. Time of onset of current stroke Other vital signs are monitored,
but the priority is blood
B. Complete physical and history pressure.
C. Current medications 5. What is a priority nursing
D. Upcoming surgical procedures assessment in the first 24
hours after admission of the
The time of onset of a stroke to client with a thrombotic
t-PA administration is critical. stroke?
Administration within 3 hours
has better outcomes. Tissue A. Cholesterol level
plasminogen activator (tPA) is B. Pupil size and pupillary response
classified as a serine protease
(enzymes that cleave peptide C. Bowel sounds
bonds in proteins). It is thus
one of the essential components D. Echocardiogram
of the dissolution of blood clots. It is crucial to monitor the
Its primary function includes pupil size and pupillary
catalyzing the conversion of response to indicate changes
plasminogen to plasmin, the around the cranial nerves.
primary enzyme involved in Pupil reactions are regulated
dissolving blood clots. by the oculomotor (III) cranial
4. During the first 24 hours nerve and are useful in
after thrombolytic therapy determining whether the brain
for ischemic stroke, the stem is intact. Pupil size and
primary goal is to control the equality is determined by a
client’s: balance between
parasympathetic and
A. Pulse sympathetic innervation.
Response to light reflects the
B. Respirations combined function of the optic
C. Blood pressure (II) and oculomotor (III)
cranial nerves.
D. Temperature
6. What is the expected outcome
Controlling the blood pressure of thrombolytic drug therapy?
is critical because an
intracerebral hemorrhage is A. Increased vascular permeability
the major adverse effect of B. Vasoconstriction
thrombolytic therapy. Blood
pressure should be maintained C. Dissolved emboli
according to the physician and
is specific to the client’s D. Prevention of hemorrhage
ischemic tissue needs and risks Thrombolytic therapy is used to
of bleeding from treatment. dissolve emboli and reestablish
MEDICAL SURGICAL NURSING SAMPLE QUESTIONNAIRE REVIEWER
, MEDICAL SURGICAL NURSING SAMPLE QUESTIONNAIRE REVIEWER
cerebral perfusion. C. An 84-year-old Japanese female.
Thrombolytic treatment is also
known as fibrinolytic or D. A 55-year-old African American
thrombolysis, to dissolve male.
dangerous intravascular clots African Americans have twice
to prevent ischemic damage by the rate of CVAs as Caucasians;
improving blood flow. males are more likely to have
Thrombosis is a significant strokes than females except in
physiological response that advanced years. Of all the risk
limits hemorrhage caused by factors, hypertension is the
large or tiny vascular injury. most common modifiable risk
7. The client diagnosed with factor for stroke. Hypertension
atrial fibrillation has is most prevalent in African-
experienced a transient Americans and also occurs
ischemic attack (TIA). Which earlier in life.
medication would the nurse 9. Which assessment data would
anticipate being ordered for indicate to the nurse that the
the client on discharge? client would be at risk for a
A. A thrombolytic medication hemorrhagic stroke?
B. A beta-blocker medication A. A blood glucose level of 480
mg/dl.
C. An anti-hyperuricemic
medication B. A right-sided carotid bruit.
D. An oral anticoagulant medication C. A blood pressure of 220/120
mmHg.
Thrombi form secondary to
atrial fibrillation. Therefore, an D. The presence of bronchogenic
anticoagulant would be carcinoma.
anticipated to prevent thrombus Uncontrolled hypertension is a
formation; and oral (warfarin risk factor for hemorrhagic
[Coumadin]) at discharge stroke, which is a ruptured
versus intravenous. Oral blood vessel in the cranium.
anticoagulation is indicated for Hypertension is the most
patients with atrial fibrillation common cause of hemorrhagic
or other sources of stroke. Long standing
cardioembolic sources of TIA. hypertension produces
8. Which client would the nurse degeneration of media,
identify as being most at risk breakage of the elastic lamina,
for experiencing a CVA? and fragmentation of smooth
muscles of arteries.
A. A 39-year-old pregnant female.
10. The nurse and unlicensed
B. A 67-year-old Caucasian male. assistive personnel (UAP) are
MEDICAL SURGICAL NURSING SAMPLE QUESTIONNAIRE REVIEWER
, MEDICAL SURGICAL NURSING SAMPLE QUESTIONNAIRE REVIEWER
caring for a client with right- client in which of the
sided paralysis. Which action following circumstances?
by the UAP requires the
nurse to intervene? A. Vomiting continues.
A. The assistant places a gait belt B. Intracranial pressure (ICP) is
around the client’s waist prior to increased.
ambulating. C. The client needs mechanical
B. The assistant places the client on ventilation.
the back with the client’s head to the D. Blood is anticipated in the
side. cerebrospinal fluid (CSF).
C. The assistant places her hand Sudden removal of CSF results
under the client’s right axilla to help in pressures lower in the
him/her move up in bed. lumbar area than the brain and
D. The assistant praises the client favors herniation of the brain;
for attempting to perform ADL’s therefore, LP is contraindicated
independently. with increased ICP. A head
computed tomogram (CT)
This action is inappropriate should be obtained before
and would require intervention performing a lumbar puncture
by the nurse because pulling on if there is a concern for
a flaccid shoulder joint could increased intracranial pressure.
cause shoulder dislocation; as Signs and symptoms of possible
always use a lift sheet for the increased intracranial pressure
client and nurse safety. Avoid include altered mental status,
pulling the affected arm. Place focal neurological deficits,
a hand behind the scapula new-onset seizure, papilledema,
when moving the upper immunocompromised state,
extremity instead of pulling malignancy, history of focal
from the arm; Utilize a lift CNS disease (stroke, focal
sheet during bed repositioning. infection, tumor), concern for
When the patient is sitting mass CNS lesion and age
provide the arm with a firm greater than 60 years old.
support surface
12. A client with a subdural
11. A client admitted to the hematoma becomes restless
hospital with a subarachnoid and confused, with dilation of
hemorrhage has complaints the ipsilateral pupil. The
of severe headache, nuchal physician orders mannitol for
rigidity, and projectile which of the following
vomiting. The nurse knows reasons?
lumbar puncture (LP) would
be contraindicated in this A. To reduce intraocular pressure.
MEDICAL SURGICAL NURSING SAMPLE QUESTIONNAIRE REVIEWER
