Question 1

After a patient experienced a brief episode of tinnitus,diplopia,and dysarthria with no residual effects,the nurse anticipates teaching the patient about

Accepted Answer

A)   cerebral aneurysm clipping.
B)   heparin intravenous infusion.
C)   oral low-dose aspirin therapy.
D)   tissue plasminogen activator (tP
A)  . C

Question 2

A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered.Which test should be done first?

Accepted Answer

A)   Complete blood count (CB
C)  
B)   Chest radiograph (Chest x-ray) 
C)   12-Lead electrocardiogram (ECG) 
D)   Noncontrast computed tomography (CT)  scan D

Question 3

For a patient who had a right hemisphere stroke the nurse establishes a nursing diagnosis of

Accepted Answer

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. A

Question 4

After receiving change-of-shift report on the following four patients,which patient should the nurse see first?

Accepted Answer

A)   A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed
B)   A 50-year-old patient who has atrial fibrillation and a new order for warfarin (Coumadin) 
C)   A 40-year-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due
D)   A 30-year-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop)  scheduled

Question 5

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?

Accepted Answer

A)   Apply an eye patch to the right eye.
B)   Approach the patient from the right side.
C)   Place objects needed on the patient's left side.
D)   Teach the patient that the left visual deficit will resolve.

Question 6

A 47-year-old patient will attempt oral feedings for the first time since having a stroke.The nurse should assess the gag reflex and then

Accepted Answer

A)   order a varied pureed diet.
B)   assess the patient's appetite.
C)   assist the patient into a chair.
D)   offer the patient a sip of juice.

Question 7

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage.Which information about the patient is most important to communicate to the health care provider?

Accepted Answer

A)   The patient's speech is difficult to understand.
B)   The patient's blood pressure is 144/90 mm Hg.
C)   The patient takes a diuretic because of a history of hypertension.
D)   The patient has atrial fibrillation and takes warfarin (Coumadin) .

Question 8

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?

Accepted Answer

A)   Keep head of bed elevated at least 30 degrees.
B)   Infuse normal saline intravenously at 75 mL/hr.
C)   Administer tissue plasminogen activator (tP
A)   per protocol.
D)   Administer a labetalol (Normodyne)  drip to keep BP less than 140/90 mm Hg.

Question 9

A male patient who has right-sided weakness after a stroke is making progress in learning to use the left hand for feeding and other activities.The nurse observes that when the patient's wife is visiting,she feeds and dresses him.Which nursing diagnosis is most appropriate for the patient?

Accepted Answer

A)   Interrupted family processes related to effects of illness of a family member
B)   Situational low self-esteem related to increasing dependence on spouse for care
C)   Disabled family coping related to inadequate understanding by patient's spouse
D)   Impaired nutrition: less than body requirements related to hemiplegia and aphasia

Question 10

A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department.Which action should the nurse take first?

Accepted Answer

A)   Monitor the blood pressure.
B)   Send the patient for a computed tomography (CT)  scan.
C)   Check the respiratory rate and effort.
D)   Assess the Glasgow Coma Scale score.

Question 11

A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved after 2 hours.The nurse will anticipate teaching the patient about

Accepted Answer

A)   alteplase (tP
A)  .
B)   aspirin (Ecotrin) .
C)   warfarin (Coumadin) .
D)   nimodipine (Nimotop) .

Question 12

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?

Accepted Answer

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.

Question 13

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?

Accepted Answer

A)   Impulsive behavior
B)   Right-sided neglect
C)   Hyperactive left-sided tendon reflexes
D)   Difficulty comprehending instructions

Question 14

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?

Accepted Answer

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.

Question 15

When teaching about clopidogrel (Plavix),the nurse will tell the patient with cerebral atherosclerosis

Accepted Answer

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.

Question 16

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting.Which assessment information is of most concern to the nurse?

Accepted Answer

A)   The pulse rate is 102 beats/min.
B)   The patient has difficulty speaking.
C)   The blood pressure is 144/86 mm Hg.
D)   There are fine crackles at the lung bases.

Question 17

Several weeks after a stroke,a 50-year-old male patient has impaired awareness of bladder fullness,resulting in urinary incontinence.Which nursing intervention will be best to include in the initial plan for an effective bladder training program?

Accepted Answer

A)   Limit fluid intake to 1200 mL daily to reduce urine volume.
B)   Assist the patient onto the bedside commode every 2 hours.
C)   Perform intermittent catheterization after each voiding to check for residual urine.
D)   Use an external "condom" catheter to protect the skin and prevent embarrassment.

Question 18

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

Accepted Answer

A)   surgical endarterectomy.
B)   transluminal angioplasty.
C)   intravenous heparin administration.
D)   tissue plasminogen activator (tP
A)   infusion.

Question 19

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness (LOC).Which nursing diagnosis do they determine has the highest priority for the patient?

Accepted Answer

A)   Impaired physical mobility related to weakness
B)   Disturbed sensory perception related to brain injury
C)   Risk for impaired skin integrity related to immobility
D)   Risk for aspiration related to inability to protect airway

Question 20

The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes.Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)?

Accepted Answer

A)   Assess the patient's gag and cough reflexes.
B)   Determine when the stroke symptoms began.
C)   Administer the prescribed short-acting insulin.
D)   Infuse the prescribed IV metoprolol (Lopressor) .

Exam 54: Nursing Management: the Patient With a Stroke