Pearson Questions Stroke
1. The nurse is caring for a patient on the stroke unit. Which should be the nurse's priority
action?
a. Instructing the patient to hyperextend the neck while swallowing
b. Teaching the patient to place food behind the front teeth on the affected side of
the mouth
c. Ordering a pureed or soft diet *
d. Monitoring swallowing studies prior to every meal
2. The nurse is planning care for a patient who has garbled speech after a stroke. Which
intervention should the nurse include?
a. Using flash cards to express needs *
b. Encouraging quick responses from the patient
c. Using long and complex sentences when speaking to the patient
d. Consulting the patient's family to discuss the patient's needs
3. The nurse is planning discharge teaching for a patient who requires assistance with
mobility and eating after experiencing a stroke. Which instruction should the nurse
include?
a. Advising the family to install grab bars next to the toilet *
b. Informing the patient there is no need to continue the inpatient therapy plan of
care
c. Having the family to encourage the patient to adhere to the existing family routine
d. Telling the family that the patient will return to their original level of mobility within
a year
4. The nurse is caring for a patient who is having difficulty eating and swallowing following
a stroke. Which rehabilitative team member should the nurse consult regarding this
issue?
a. Dietitian
b. Occupational therapist*
c. Physical therapist
d. Case manager
5. The patient asks the nurse how a carotid endarterectomy increases the blood supply to
the brain. Which response by the nurse is accurate?
a. "Plaque from your carotid artery is removed to improve perfusion to the brain." *
b. "A balloon will be inserted into your carotid artery to make it wider and place a
stent."
c. "A bypass is established around the plaque buildup in your carotid artery."
6. After teaching about stroke in a child, the nurse asked a group of parents to list the
clinical manifestations. Which response by a parent indicates a need for further
education?
a. Unilateral neglect
b. Severe headaches
c. Dizziness and mood changes
d. Hyperalertness*
7. The nurse is caring for a patient who is suspected of having a hemorrhagic stroke.
Which diagnostic procedure should the nurse expect to be performed first?
a. Magnetic resonance imaging (MRI)
b. PLAC test
c. Computerized tomography (CT) scan *
d. Lumbar puncture for cerebrospinal fluid examination
8. A patient is diagnosed with stroke at the right anterior cerebral artery. The nurse asks the
patient’s daughter, “What changes have you noticed in your mother?” Which response
by the daughter would be consistent with the patient’s diagnosis?
a. “She doesn’t seem to see the food on her plate.”
b. “I have to make all the decisions for my mother.” *
c. “She has difficulty walking.”
d. “I have to really watch her when she’s eating.”
9. The nurse is teaching a patient who had a stroke how to perform active range of motion
exercises. Which patient statement indicates an understanding of the teaching?
a. "I will use slow movements and stop if pain occurs."
b. "I will perform each of the exercises three to four times per day, in the same
order."
c. "If my affected side cannot move independently, I will practice on the unaffected
side only."
d. "Performing range of motion exercises helps me to strengthen my unaffected
side only."
10. The nurse is caring for a patient diagnosed with stroke. Which complication is the nurse
least likely to expect?
a. Dysphagia
b. Stool impaction
c. Diarrhea*
d. Constipation
11. Which should the nurse state as a risk factor for cardiovascular accidents?
a. Hyperlipidemia controlled by prescribed oral medication
b. History of type 1 diabetes mellitus since adolescence *
c. Consumption of one glass of red wine with dinner
d. Cessation of cigarette smoking for a period of 5 years
12. The nurse is caring for a patient who is suspected of having a cerebral infarction. Which
intervention should be the priority?
a. Head computerized tomography (CT) scan
b. Complete history and physical assessment *
c. Lumbar puncture for cerebrospinal fluid (CSF) examination
d. PLAC test
13. The nurse is teaching a patient about a transient ischemic attack (TIA). Which statement
should the nurse include?
a. "A TIA can be a warning sign of an impending larger stroke." *
b. "TIAs cause brain cells to die and leave a small cavity in the brain tissue."
c. "TIAs usually involve one large artery in the brain prior to stroke."
d. "TIAs are caused by blood clots that break off from larger clots in the body."
14. The nurse suspects that a newborn may be experiencing a stroke. Which diagnostic
procedure should the nurse anticipate being ordered to confirm the suspicion?
a. Fetal ultrasound
b. Magnetic resonance imaging (MRI) *
c. X-ray
d. Blood glucose check
15. The nurse on the rehabilitation unit is planning care for a patient who recently
experienced a stroke. Which intervention should the nurse implement to promote
mobility for this patient?
a. Encouraging fluid intake up to 2000 mL per day
b. Administering oxygen per order
c. Helping the patient to the bathroom every 2 hours
d. Assisting with range of motion exercises *
16. The nurse is assessing a 30-year-old woman who states that her mother had a stroke
recently. Which risk factor should the nurse consider significant for this patient?
a. Insomnia
b. Oral contraceptive use *
c. Active lifestyle
d. Menopause
17. The nurse is caring for a patient on the stroke rehabilitation unit. Which intervention
should the nurse question?
a. Decreasing fluid intake to prevent aspiration and decrease urinary frequency*
b. Encouraging bladder training by having the patient void on a schedule
c. Teaching the patient Kegel exercises
d. Using positive reinforcement
18. The nurse is teaching the parent of a child who is diagnosed with sickle cell disease
about the signs and symptoms of stroke. Which statement by the parent indicates the
need for further teaching?
a. "I will monitor my child for severe headaches."
b. "I will monitor my child for sleepiness and unilateral neglect."
c. "I will monitor my child for hyperalertness."*
d. "I will monitor my child for dizziness and mood changes."
19. A patient is preparing to go home following a recent stroke. Which behavior indicates
that the patient has met nursing care plan goals?
a. The patient is sipping water with meals to help with swallowing.
b. The patient is participating in range of motion exercises each day.
c. The patient has experienced minimal complications from reduced mobility and
dysphagi*
d. The patient's family is at the bedside daily assisting the patient with all activities
of daily living.
20. The nurse is completing a health history for a patient who is suspected of having an
acute stroke. Which assessment finding should the nurse immediately report to the
healthcare provider?
a. The onset of symptoms was 2.5 hours ago.
b. The patient has a 20-year history of smoking two packs of cigarettes per day.
c. The patient's father died of a stroke.
d. The patient has never had a stroke before.
21. A patient's family asks why the healthcare provider ordered heparin instead of tPA for a
family member who experienced a thrombotic stroke 5 hours earlier. Which response by
the nurse is accurate?
a. "Heparin is the best drug on the market to break up clots that are causing stroke."
b. "TPA must be given within 3 hours of the onset of symptoms because of serious
side effects."
c. "Heparin is given initially followed by an infusion tPA to finish breaking up the
clot."
d. "Heparin starts to break up the clot and is followed by warfarin to prevent further
clotting."
22. The patient asks the nurse if they are at risk for a stroke. Which should the nurse ask
about in the health history to determine the patient's risk?
a. Use of cigarettes
b. Skin integrity
c. Breath sounds
d. Level of consciousness
23. A patient diagnosed with a thrombotic stroke is receiving treatment to restore normal
cerebral blood flow. Which process does the nurse understand may cause further
damage to the brain?
a. The damaged cells release chemicals affecting other cells around them. *
b. The blood supply is cut off to part of the brain.
c. Localized blood flow gets restore
d. The cell membranes allow water to enter the cell, causing damage to the cells.
24. The nurse provided teaching to a patient about the risk of stroke during pregnancy.
Which patient statement indicates a need for further teaching?
a. “Preeclampsia increases the risk for a stroke.”
b. “Increased hormone levels change the blood vessel walls, which increases the
risk of clotting.”
c. “Increased hormone levels cause increased clotting times.” *
d. “The increased blood pressure associated with pregnancy increases stroke risk.”
25. The nurse is caring for a patient poststroke. Which action is most important prior to
feeding the patient?
a. Placing the food in the unaffected side of the mouth
b. Sitting the patient upright
c. Ordering a soft or pureed diet
d. Assessing the results of the swallowing studies
26. The nurse is teaching a patient about a carotid endarterectomy. Which explanation
should the nurse use to describe the procedure?
a. A carotid endarterectomy removes atherosclerotic plaque from the carotid
arteries.
b. A carotid endarterectomy shoots pulses of water through the artery to widen the
blood vessel.
c. A carotid endarterectomy uses a stent to enlarge the diameter of the carotid
artery.
d. A carotid endarterectomy reroutes blood flow through cerebral tissue.
NCLEX Bank
1. Which description of an acute embolic stroke given by the nurse is most​accurate?
a. The local cerebral tissue becomes engorged with blood from a ruptured cerebral
vessel.
b. Cerebral vascular pressure exceeds the elasticity of the vessel​wall, resulting in
hemorrhages.
c. Infarcted areas in the brain slough​off, leaving cavities in the brain tissue.
d. A blood clot lodges in a cerebral vessel and blocks blood flow. *
2. The nurse is teaching a class about the causes of a hemorrhagic stroke. Which should
the nurse​include? (Select all that​apply.)
a. Damage to the blood–brain barrier
b. Traumatic injury to the brain *
c. Ruptured aneurysm in the brain *
d. Atherosclerotic plaque breaking off in the artery
e. Rupture of a fragile arterial vessel in the brain *
3. The nurse is teaching a client about the cause of a transient ischemic attack​(TIA).
Which should the nurse​include?
a. Sudden intracranial bleed
b. Brief period of a neurologic deficit *
c. Formation of a clot in a blood vessel
d. Vascular blockage
4. A client was diagnosed with a thrombotic stroke of the vertebral artery. Which
assessment does the nurse expect to​make?
a. Dysphagia *
b. Contralateral paralysis
c. Global aphasia
d. Stupor
5. An adult client had a stroke involving the internal carotid artery of the dominant
hemisphere. The nurse should anticipate that the client will have difficulty with which​
function?
a. Speaking *
b. Swallowing
c. Staying alert
d. Retaining urine
6. The nurse is caring for a client recovering from a stroke in the rehabilitation setting.
Which is the goal of care during this​stage?
a. Dispatching rapid emergency medical services​(EMS)
b. Improving muscle strength and coordination *
c. Diagnosing the type and cause of stroke
d. Minimizing brain injury
7. The nurse on the stroke rehabilitation unit is planning care for a client who is
experiencing vision and equilibrium​deficits, altered​proprioception, hemianopia, and
neglect syndrome. Which nursing therapy is the most important to​include?
a. Providing reassurance and support *
b. Developing an alternate means of communicating
c. Maintaining​fluid, oxygen, and nutritional status
d. Providing behavioral and cognitive therapy when the condition stabilizes
8. The nurse caring for a client with a history of transient ischemic attacks​(TIAs) is
reviewing medications ordered to prevent a stroke. Which medication therapy requires​
follow-up?
a. Beta blocker *
b. Antiplatelet
c. Thiazide diuretic
d. Anticoagulant
9. The nurse taught a group of clients recovering from a stroke how to perform active​
range-of-motion exercises. Which client requires further​teaching?
a. The client performing​flexion, extension, and hyperextension of the hips
bilaterally
b. The client with​left-sided paralysis using the right arm to help flex and extend the
left wrist
c. The client with​right-sided paralysis flexing and extending only the left knee *
d. The client performing extension and hyperextension of the neck
10. The nurse is reviewing interventions aimed at maintaining cerebral perfusion in a client
who had a thrombotic stroke. Which intervention should the nurse​question?
a. Placing the client in a​side-lying position
b. Monitoring mental status and level of consciousness
c. Encouraging active​range-of-motion exercises *
d. Monitoring respiratory status
11. A client has a history of transient ischemic attacks​(TIAs). Which medication does the
nurse expect to find in the​client's list of​prescriptions?
a. Stool softener
b. Beta blocker
c. Anticoagulant
d. Antiplatelet *
12. A client who is diagnosed with a stroke has an order for a tissue plasminogen activator​
(tPA). Which circumstance does the nurse suspect is​present?
a. The stroke must be hemorrhagic in nature.
b. Aspirin therapy must have been received for 6 months for tPA to be effective.
c. Atherosclerotic buildup in affected arteries must be greater than​90%.
d. The stroke must have occurred within 3 hours of administering the medication. *
13. A client who is diagnosed with stroke is very drowsy but can respond when awakene
Using the National Institutes of Health Stroke​Scale, which level of consciousness should
the nurse​document?
a. 0
b. 1 *
c. 3
d. 2
14. A client who had a stroke secondary to cerebral stenosis discussed surgical options with
the surgeon. Which option should the nurse anticipate will be​performed?
a. Carotid angioplasty with stenting *
b. Extracranial–intracranial bypass
c. Carotid endarterectomy
d. Cautious observation only
15. A client diagnosed with a stroke is having difficulty walking and may require the use of a
walker. Which area should the nurse make a referral​to?
a. Occupational therapy
b. Home health
c. Physical therapy *
d. Speech and language therapy
16. The nurse is reviewing the plan of care for a client who is unresponsive following a
stroke. Which intervention should the nurse​question?
a. Monitoring lower extremities for symptoms of thrombophlebitis
b. Elevating the head of the bed 30 degrees
c. Encouraging active​range-of-motion exercises *
d. Turning the client every 2 hours
17. The nurse is reviewing documentation of a physical examination of a client who is
suspected of having a stroke. Which documentation requires​follow-up?
a. Stroke scale completed
b. Onset of facial drooping at 1430 *
c. ​Right-sided grip stronger than​left-sided grip
d. Alert and oriented to person but not oriented to place or time
18. The nurse is planning care for a client who has unilateral neglect and​left-sided paralysis
after experiencing a thrombotic stroke. Which goal of care should the nurse​choose?
a. The client will improve communication techniques.
b. The client will maintain bedrest.
c. The client will participate in therapies to prevent contractures. *
d. The​client's blood pressure will remain within​40% of normal.
19. The nurse is observing the unlicensed assistive personnel​(UAP) helping a client with
unilateral neglect of the right side perform​self-care. Which statement by the UAP
requires an intervention by the​nurse?
a. ​"The occupational therapist will assist you in learning to walk using a​walker."
b. ​"When getting​dressed, first put clothing on the left​side." *
c. ​"Use the left arm to​bathe, brush​teeth, comb​hair, and​eat."
d. "​ The occupational therapist will teach you how to promote upper extremity​
strength."
20. After performing swallowing studies for a client recovering from a​stroke, the speech
therapist recommends a pureed diet and​honey-thick liquids. Which is a priority for the​
nurse?
a. Carefully monitoring for coughing after giving the client a thickened beverage *
b. Calling the healthcare provider about the results
c. Ordering a pureed diet
d. Documenting the results of the swallowing studies
Test Bank
1. A client with a suspected transient ischemic attack​(TIA) presents to the emergency
department with aphasia. Based on this​data, the nurse plans care based on ischemia to
which portion of the​brain?
a. Right hemisphere of the brain
b. Vertebral artery
c. Left hemisphere of the brain*
d. Anterior cerebral artery
2. While completing a health history with an older adult​client, the nurse learns that the
client experienced a transient ischemic attack​(TIA) several months ago. The nurse
should recognize​that:
a. the client will have minimal symptoms should a stroke occur.
b. the client will not experience a stroke in the future.
c. the client is at risk for an ischemic thrombotic stroke.*
d. the client is at high risk for a hemorrhagic stroke.
3. During a​6-month well-baby check​up, the mother mentions to the nurse that her infant
seems to be sleeping just as much as she did as a​newborn, and she seems to do
everything with her left hand. The nurse recognizes that these are warning signs of
stroke that occurred early in life. What other question should the nurse ask to assess for
signs of​stroke?
a. ​"Does your baby vomit frequently after​feeding?"
b. ​"Have you noticed your baby having trouble forming​words?"
c. ​"Have you noticed your baby jerking any muscles of the​face, arms, or​legs?"*
d. ​"Does your baby frequently seem to lose her​balance?"
4. The nurse is instructing the spouse of a client with a stroke on how to do passive​
range-of-motion exercises to the affected limbs. Which rationale for this intervention will
the nurse include in the teaching​session?
a. Maintain joint flexibility*
b. Maintain cardiopulmonary function
c. Improve muscle strength
d. Improve endurance
5. While teaching a wellness class on the warning signs of​stroke, a participant asks the​
nurse, "What's the most important thing for me to​remember?" What is an appropriate
response by the​nurse?
a. ​"Call 911 if you notice a gradual onset of paralysis or​confusion."
b. ​"Be alert for sudden weakness or​numbness."*
c. ​"Know your family​history."
d. ​"Keep a list of your​medications."
6. A client diagnosed with a stroke is going to receive treatment with fibrinolytic therapy
using the recombinant tissue plasminogen activator alteplase​(rt-PA). Which information
should the nurse include when performing medication teaching for the​client's family?
a. Indicated if the stroke symptoms have occurred within the last 6 hours
b. Administered to break up existing clots and increase cerebral blood flow*
c. Used to treat thrombotic and hemorrhagic strokes
d. Not associated with serious complications
7. The community nurse is teaching a class at the community center regarding the cultural
and ethnic risk factors for stroke. Which statement should nurse include in this​
presentation?
a. Caucasians have an increased incidence of intracerebral hemorrhage.
b. Asian Americans are more likely to die following a stroke than Whites.
c. The prevalence of hypertension among Hispanics is the highest in the world.
d. African Americans have almost twice the number of​first-ever strokes compared
with Whites.*
8. What type of stroke occurs when the blood supply to a part of the brain is cut off by a​
thrombus, embolus, or​stenosis?
a. Ischemic stroke*
b. Intracerebral stroke
c. Subarachnoid stroke
d. Hemorrhagic stroke
9. The medication clopidogrel​(Plavix) is most commonly given during which stage of
treatment for a​stroke?
a. Recovery care after a stroke
b. Acute care immediately after a stroke
c. Rehabilitation after a stroke
d. Stroke prevention*
10. The nurse is planning care for a client admitted with a stroke. Which intervention would
support the​client's sensorimotor​needs?
a. Talk loudly and distinctly.
b. Encourage use of nonaffected arm to feed​self, bathe, and dress.*
c. Speak in normal conversational pattern and tones.
d. Provide complete care.
11. The nurse is providing community health teaching on stroke in children and adolescents.
Which risk factors for this population should the nurse​identify?
a. Hypertension
b. Head trauma*
c. Dysrhythmias
d. Arteriosclerosis
12. After a​stroke, sensory-perceptual changes increase the​client's risk for​what?
a. Bleeding
b. Aspiration
c. Infection
d. Injury*