Lewis's Medical Surgical Nursing Test Bank 11th Edition [Harding]
Chapter 57 - Stroke
1. After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with
no residual effects, the nurse anticipates teaching the patient about
A. cerebral aneurysm clipping.
B. heparin intravenous infusion.
C. oral low-dose aspirin therapy.
D. tissue plasminogen activator (tPA).
Answer: C
Explanation: The symptoms are consistent with a transient ischemic attack (TIA).
Antiplatelet therapy like low-dose aspirin is prescribed to reduce the risk of future stroke. tPA
is for acute ischemic stroke, heparin is not routine for TIA, and the symptoms do not indicate
an aneurysm.
2. A 68-year-old patient is being admitted with a possible stroke. Which information
from the assessment indicates that the nurse should consult with the health care
provider before giving the prescribed aspirin?
A. The patient has dysphasia.
B. The patient has atrial fibrillation.
C. The patient reports that symptoms began with a severe headache.
D. The patient has a history of brief episodes of right-sided hemiplegia.
Answer: C
Explanation: A sudden severe headache suggests a subarachnoid hemorrhage, for which
aspirin is contraindicated due to increased bleeding risk. Dysphasia, atrial fibrillation, and a
history of TIAs are not contraindications.
3. A 73-year-old patient with a stroke experiences facial drooping on the right side and
right-sided arm and leg paralysis. When admitting the patient, which clinical
manifestation will the nurse expect to find?
A. Impulsive behavior
B. Right-sided neglect
C. Hyperactive left-sided tendon reflexes
D. Difficulty comprehending instructions
Answer: D
,Explanation: Right-sided weakness indicates a left-brain stroke, which often causes language
comprehension deficits (e.g., aphasia). Left-sided neglect and impulsivity are more common
in right-brain strokes. Reflex changes are not the primary focus.
4. During the change of shift report a nurse is told that a patient has an occluded left
posterior cerebral artery. The nurse will anticipate that the patient may have
A. dysphasia.
B. confusion.
C. visual deficits.
D. poor judgment.
Answer: C
Explanation: Occlusion of the posterior cerebral artery commonly causes visual field deficits
(e.g., homonymous hemianopsia). Aphasia is associated with middle cerebral artery
involvement; cognitive changes are more typical of anterior cerebral artery occlusion.
5. When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral
atherosclerosis
A. to monitor and record the blood pressure daily.
B. that Plavix will dissolve clots in the cerebral arteries.
C. that Plavix will reduce cerebral artery plaque formation.
D. to call the health care provider if stools are bloody or tarry.
Answer: D
Explanation: Clopidogrel is an antiplatelet agent that increases bleeding risk. Patients should
report signs of bleeding, such as bloody or tarry stools. It does not lower BP, dissolve clots,
or reduce plaque.
6. A patient with carotid atherosclerosis asks the nurse to describe a carotid
endarterectomy. Which response by the nurse is accurate?
A. The obstructing plaque is surgically removed from an artery in the neck.
B. The diseased portion of the artery in the brain is replaced with a synthetic graft.
C. A wire is threaded through an artery in the leg to the clots in the carotid artery and the
clots are removed.
D. A catheter with a deflated balloon is positioned at the narrow area, and the balloon is
inflated to flatten the plaque.
Answer: A
,Explanation: A carotid endarterectomy involves surgical removal of plaque from the carotid
artery. The other options describe angioplasty, stenting, or mechanical clot retrieval
procedures.
7. A patient admitted with possible stroke has been aphasic for 3 hours and his current
blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should
the nurse question?
A. Keep head of bed elevated at least 30 degrees.
B. Infuse normal saline intravenously at 75 mL/hr.
C. Administer tissue plasminogen activator (tPA) per protocol.
D. Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg.
Answer: D
Explanation: In acute stroke, elevated BP may be necessary to maintain cerebral perfusion.
Aggressive lowering of BP is not recommended unless systolic BP is >220 mm Hg or mean
arterial pressure is >130 mm Hg. The other orders are appropriate.
8. A 56-year-old patient arrives in the emergency department with hemiparesis and
dysarthria that started 2 hours previously, and health records show a history of several
transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for
A. surgical endarterectomy.
B. transluminal angioplasty.
C. intravenous heparin administration.
D. tissue plasminogen activator (tPA) infusion.
Answer: D
Explanation: The patient's symptoms and timeline suggest an acute ischemic stroke. tPA may
be administered if within 4.5 hours of symptom onset and no contraindications exist. Heparin,
angioplasty, or endarterectomy are not first-line emergency treatments.
9. A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse
identifies the nursing diagnosis of impaired verbal communication. An appropriate
nursing intervention to help the patient communicate is to
A. ask questions that the patient can answer with yes or no.
B. develop a list of words that the patient can read and practice reciting.
C. have the patient practice her facial and tongue exercises with a mirror.
D. prevent embarrassing the patient by answering for her if she does not respond.
Answer: A
, Explanation: Using yes/no questions reduces frustration and facilitates communication for a
patient with expressive aphasia. Reading or speech exercises may be too challenging initially,
and answering for the patient can increase frustration.
10. For a patient who had a right hemisphere stroke the nurse establishes a nursing
diagnosis of
A. risk for injury related to denial of deficits and impulsiveness.
B. impaired physical mobility related to right-sided hemiplegia.
C. impaired verbal communication related to speech-language deficits.
D. ineffective coping related to depression and distress about disability.
Answer: A
Explanation: Right-brain strokes often cause left-sided neglect, impulsivity, and poor
judgment, increasing injury risk. Left-brain strokes typically cause language deficits and
depression. Hemiplegia is contralateral to the brain lesion.
11. When caring for a patient with a new right-sided homonymous hemianopsia
resulting from a stroke, which intervention should the nurse include in the plan of care?
A. Apply an eye patch to the right eye.
B. Approach the patient from the right side.
C. Place objects needed on the patients left side.
D. Teach the patient that the left visual deficit will resolve.
Answer: C
Explanation: With right homonymous hemianopsia, the patient cannot see in the right visual
field. Placing items on the unaffected left side ensures they are within the patient's field of
vision. Patching is not appropriate, and the deficit may not resolve.
12. The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body
requirements related to impaired self-feeding ability for a left-handed patient with left-
sided hemiplegia. Which intervention should be included in the plan of care?
A. Provide a wide variety of food choices.
B. Provide oral care before and after meals.
C. Assist the patient to eat with the right hand.
D. Teach the patient the chin-tuck technique.
Answer: C
Explanation: The patient's left-sided weakness impairs self-feeding. Teaching the patient to
use the unaffected right hand promotes independence. The other options do not address the
core problem of impaired self-feeding.
Chapter 57 - Stroke
1. After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with
no residual effects, the nurse anticipates teaching the patient about
A. cerebral aneurysm clipping.
B. heparin intravenous infusion.
C. oral low-dose aspirin therapy.
D. tissue plasminogen activator (tPA).
Answer: C
Explanation: The symptoms are consistent with a transient ischemic attack (TIA).
Antiplatelet therapy like low-dose aspirin is prescribed to reduce the risk of future stroke. tPA
is for acute ischemic stroke, heparin is not routine for TIA, and the symptoms do not indicate
an aneurysm.
2. A 68-year-old patient is being admitted with a possible stroke. Which information
from the assessment indicates that the nurse should consult with the health care
provider before giving the prescribed aspirin?
A. The patient has dysphasia.
B. The patient has atrial fibrillation.
C. The patient reports that symptoms began with a severe headache.
D. The patient has a history of brief episodes of right-sided hemiplegia.
Answer: C
Explanation: A sudden severe headache suggests a subarachnoid hemorrhage, for which
aspirin is contraindicated due to increased bleeding risk. Dysphasia, atrial fibrillation, and a
history of TIAs are not contraindications.
3. A 73-year-old patient with a stroke experiences facial drooping on the right side and
right-sided arm and leg paralysis. When admitting the patient, which clinical
manifestation will the nurse expect to find?
A. Impulsive behavior
B. Right-sided neglect
C. Hyperactive left-sided tendon reflexes
D. Difficulty comprehending instructions
Answer: D
,Explanation: Right-sided weakness indicates a left-brain stroke, which often causes language
comprehension deficits (e.g., aphasia). Left-sided neglect and impulsivity are more common
in right-brain strokes. Reflex changes are not the primary focus.
4. During the change of shift report a nurse is told that a patient has an occluded left
posterior cerebral artery. The nurse will anticipate that the patient may have
A. dysphasia.
B. confusion.
C. visual deficits.
D. poor judgment.
Answer: C
Explanation: Occlusion of the posterior cerebral artery commonly causes visual field deficits
(e.g., homonymous hemianopsia). Aphasia is associated with middle cerebral artery
involvement; cognitive changes are more typical of anterior cerebral artery occlusion.
5. When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral
atherosclerosis
A. to monitor and record the blood pressure daily.
B. that Plavix will dissolve clots in the cerebral arteries.
C. that Plavix will reduce cerebral artery plaque formation.
D. to call the health care provider if stools are bloody or tarry.
Answer: D
Explanation: Clopidogrel is an antiplatelet agent that increases bleeding risk. Patients should
report signs of bleeding, such as bloody or tarry stools. It does not lower BP, dissolve clots,
or reduce plaque.
6. A patient with carotid atherosclerosis asks the nurse to describe a carotid
endarterectomy. Which response by the nurse is accurate?
A. The obstructing plaque is surgically removed from an artery in the neck.
B. The diseased portion of the artery in the brain is replaced with a synthetic graft.
C. A wire is threaded through an artery in the leg to the clots in the carotid artery and the
clots are removed.
D. A catheter with a deflated balloon is positioned at the narrow area, and the balloon is
inflated to flatten the plaque.
Answer: A
,Explanation: A carotid endarterectomy involves surgical removal of plaque from the carotid
artery. The other options describe angioplasty, stenting, or mechanical clot retrieval
procedures.
7. A patient admitted with possible stroke has been aphasic for 3 hours and his current
blood pressure (BP) is 174/94 mm Hg. Which order by the health care provider should
the nurse question?
A. Keep head of bed elevated at least 30 degrees.
B. Infuse normal saline intravenously at 75 mL/hr.
C. Administer tissue plasminogen activator (tPA) per protocol.
D. Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg.
Answer: D
Explanation: In acute stroke, elevated BP may be necessary to maintain cerebral perfusion.
Aggressive lowering of BP is not recommended unless systolic BP is >220 mm Hg or mean
arterial pressure is >130 mm Hg. The other orders are appropriate.
8. A 56-year-old patient arrives in the emergency department with hemiparesis and
dysarthria that started 2 hours previously, and health records show a history of several
transient ischemic attacks (TIAs). The nurse anticipates preparing the patient for
A. surgical endarterectomy.
B. transluminal angioplasty.
C. intravenous heparin administration.
D. tissue plasminogen activator (tPA) infusion.
Answer: D
Explanation: The patient's symptoms and timeline suggest an acute ischemic stroke. tPA may
be administered if within 4.5 hours of symptom onset and no contraindications exist. Heparin,
angioplasty, or endarterectomy are not first-line emergency treatments.
9. A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse
identifies the nursing diagnosis of impaired verbal communication. An appropriate
nursing intervention to help the patient communicate is to
A. ask questions that the patient can answer with yes or no.
B. develop a list of words that the patient can read and practice reciting.
C. have the patient practice her facial and tongue exercises with a mirror.
D. prevent embarrassing the patient by answering for her if she does not respond.
Answer: A
, Explanation: Using yes/no questions reduces frustration and facilitates communication for a
patient with expressive aphasia. Reading or speech exercises may be too challenging initially,
and answering for the patient can increase frustration.
10. For a patient who had a right hemisphere stroke the nurse establishes a nursing
diagnosis of
A. risk for injury related to denial of deficits and impulsiveness.
B. impaired physical mobility related to right-sided hemiplegia.
C. impaired verbal communication related to speech-language deficits.
D. ineffective coping related to depression and distress about disability.
Answer: A
Explanation: Right-brain strokes often cause left-sided neglect, impulsivity, and poor
judgment, increasing injury risk. Left-brain strokes typically cause language deficits and
depression. Hemiplegia is contralateral to the brain lesion.
11. When caring for a patient with a new right-sided homonymous hemianopsia
resulting from a stroke, which intervention should the nurse include in the plan of care?
A. Apply an eye patch to the right eye.
B. Approach the patient from the right side.
C. Place objects needed on the patients left side.
D. Teach the patient that the left visual deficit will resolve.
Answer: C
Explanation: With right homonymous hemianopsia, the patient cannot see in the right visual
field. Placing items on the unaffected left side ensures they are within the patient's field of
vision. Patching is not appropriate, and the deficit may not resolve.
12. The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body
requirements related to impaired self-feeding ability for a left-handed patient with left-
sided hemiplegia. Which intervention should be included in the plan of care?
A. Provide a wide variety of food choices.
B. Provide oral care before and after meals.
C. Assist the patient to eat with the right hand.
D. Teach the patient the chin-tuck technique.
Answer: C
Explanation: The patient's left-sided weakness impairs self-feeding. Teaching the patient to
use the unaffected right hand promotes independence. The other options do not address the
core problem of impaired self-feeding.
