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 mostaccurate? a. The local cerebral tissue becomes engorged with blood from a ruptured cerebral vessel. b. Cerebral vascular pressure exceeds the elasticity of the vesselwall, resulting in hemorrhages. c. Infarcted areas in the brain sloughoff, 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 nurseinclude? (Select all thatapply.) 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 nurseinclude? 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 tomake? 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 thisstage? 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 equilibriumdeficits, alteredproprioception, hemianopia, and neglect syndrome. Which nursing therapy is the most important toinclude? a. Providing reassurance and support * b. Developing an alternate means of communicating c. Maintainingfluid, 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 furtherteaching? a. The client performingflexion, extension, and hyperextension of the hips bilaterally b. The client withleft-sided paralysis using the right arm to help flex and extend the left wrist c. The client withright-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 nursequestion? a. Placing the client in aside-lying position b. Monitoring mental status and level of consciousness c. Encouraging activerange-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 theclient's list ofprescriptions? 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 ispresent? 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 than90%. 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 StrokeScale, which level of consciousness should the nursedocument? 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 beperformed? 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 referralto? 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 nursequestion? a. Monitoring lower extremities for symptoms of thrombophlebitis b. Elevating the head of the bed 30 degrees c. Encouraging activerange-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 requiresfollow-up? a. Stroke scale completed b. Onset of facial drooping at 1430 * c. Right-sided grip stronger thanleft-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 andleft-sided paralysis after experiencing a thrombotic stroke. Which goal of care should the nursechoose? a. The client will improve communication techniques. b. The client will maintain bedrest. c. The client will participate in therapies to prevent contractures. * d. Theclient's blood pressure will remain within40% of normal. 19. The nurse is observing the unlicensed assistive personnel(UAP) helping a client with unilateral neglect of the right side performself-care. Which statement by the UAP requires an intervention by thenurse? a. "The occupational therapist will assist you in learning to walk using awalker." b. "When gettingdressed, first put clothing on the leftside." * c. "Use the left arm tobathe, brushteeth, combhair, andeat." d. " The occupational therapist will teach you how to promote upper extremity strength." 20. After performing swallowing studies for a client recovering from astroke, the speech therapist recommends a pureed diet andhoney-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 thisdata, the nurse plans care based on ischemia to which portion of thebrain? 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 adultclient, the nurse learns that the client experienced a transient ischemic attack(TIA) several months ago. The nurse should recognizethat: 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 a6-month well-baby checkup, the mother mentions to the nurse that her infant seems to be sleeping just as much as she did as anewborn, 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 ofstroke? a. "Does your baby vomit frequently afterfeeding?" b. "Have you noticed your baby having trouble formingwords?" c. "Have you noticed your baby jerking any muscles of theface, arms, orlegs?"* d. "Does your baby frequently seem to lose herbalance?" 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 teachingsession? 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 ofstroke, a participant asks the nurse, "What's the most important thing for me toremember?" What is an appropriate response by thenurse? a. "Call 911 if you notice a gradual onset of paralysis orconfusion." b. "Be alert for sudden weakness ornumbness."* c. "Know your familyhistory." d. "Keep a list of yourmedications." 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 theclient'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 offirst-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, orstenosis? 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 astroke? 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 theclient's sensorimotorneeds? a. Talk loudly and distinctly. b. Encourage use of nonaffected arm to feedself, 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 nurseidentify? a. Hypertension b. Head trauma* c. Dysrhythmias d. Arteriosclerosis 12. After astroke, sensory-perceptual changes increase theclient's risk forwhat? a. Bleeding b. Aspiration c. Infection d. Injury*
