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NCLEX med surg stroke Questions And Correct Detailed Answers (Verified Answers) Already Graded A+
- During the acute phase of a stroke, the nurse assesses the patient's vital signs and
neurologic status every 4 hours. A cardiovascular sign that the nurse would see as the body attempts to increase cerebral blood flow is: a. hypertension b. fluid overload c.
cardiac dysrhythmias d. S3 and S4 heart sounds Correct Answer: A
- A diagnosis of a ruptured cerebral aneurysm has been made in a patient with
manifestations of a stroke. The nurse anticipates that treatment options that would be evaluated for the patient include: a. hyperventilation therapy b. surgical clipping of the aneurysm c. administration of hyperosmotic agents d. administration of thrombolytic
therapy Correct Answer: B
- The priority intervention in the emergency department for the patient with a stroke
is: a. intravenous fluid replacement b. administration of osmotic diuretics to reduce cerebral edema c. initiation of hypothermia to decrease the oxygen needs of the brain d.maintenance of respiratory function with a patent airway and oxygen administration
Correct Answer: D
- The incidence of ischemic stroke in patients with TIAs and other risk factors is
reduced with administration of: a. furosemide (Lasix) b. lovastatin (Mevacor) c. daily low
dose aspirin d. nimodipine (Nimotop) Correct Answer: C
- A carotid endarterectomy is being considered as a treatment for a patient who has
had several TIAs. The nurse explains to the patient that this surgery: a. is used to restore blood to the brain following an obstruction of a cerebral artery b. involves intracranial surgery to join a superficial extracranial artery to an intracranial artery c.involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke d. is sued to open a stenosis in a carotid artery with a balloon and stent to restore
cerebral circulation Correct Answer: C
- A patient is admitted to the hospital with a left hemiplegia. To determine the size
and location and to ascertain whether a stroke is ischemic or hemorrhagic, the nurse anticipates that the health care provider will request a: a. CT scan b. lumbar puncture c.
cerebral arteriogram d. positron emission tomography (PET) Correct Answer: A
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- The neurologic functions that are affected by a stroke are primarily related to: a. the
amount of tissue area involved b. the rapidity of onset of symptoms c. the brain area perfused by the affected artery d. the presence or absence of collateral circulation Correct
Answer: C
- A patient comes to the emergency department immediately after experiencing
numbness of the face and an inability to speak, but while the patient awaits examination, the symptoms disappear and the patient request discharge. The nurse stresses that it is important for the patient to be evaluated primarily because: a. the patient has probably experienced an asymptomatic lacunar stroke b. the symptoms are likely to return and progress to worsening neurologic deficit in the next 24 hours c.neurologic deficits that are transient occur most often as a result of small hemorrhages that clot off d. the patient has probably experienced a transient ischemic attack (TIA),
which is a sign of progressive cerebral vascular disease Correct Answer: D
- A thrombus that develops in a cerebral artery does not always cause a loss of
neurologic function because: a. the body can dissolve the atherosclerotic plaques as they form b. some tissues of the brain do not require constant blood supply to prevent damage c. circulation through the circle of Willis may provide blood supply to the affected area of the brain d. neurologic deficits occur only when major arteries are occluded by
thrombus formation around an atherosclerotic plaque Correct Answer: C
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- In promoting health maintenance for prevention of strokes, the nurse understands
that the highest risk for the most common type of stroke is present in: a. African Americans b. women who smoke c. individuals with hypertension and diabetes d. those
who are obese with high dietary fat intake Correct Answer: C
- A nursing intervention is indicated for the patient with hemiplegia is: a. the use of a
footboard to prevent plantar flexion b. immobilization of the affected arm against the chest with a sling c. positioning the patient in bed with each joint lower than the joint proximal to it d. having the patient perform passive ROM of the affected limb with the unaffected limb
Correct Answer: D
- A newly admitted patient who has suffered a right sided brain stroke has a nursing
diagnosis of disturbed visual sensory perception related to homonymous hemianopsia. Early in the care of the patient, the nurse should: a. place objects on the
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right side within the patient's field of vision b. approach the patient from the left side to encourage the patient to turn the head c. place objects on the patient's left side to assess the patient's ability to compensate d. patch the affected eye to encourage the patient to
turn the head to scan the environment Correct Answer: A
- Four days following a stroke, a patient is to start oral fluids and feedings. Before
feeding the patient, the nurse should first: a. check the patient's gag reflex b. order a soft diet for the patient c. raise the head of the bed to sitting position d. evaluate the patient's
ability to swallow small sips of ice water Correct Answer: A
- An appropriate food for a patient with a stroke who has mild dysphagia is: a. fruit
- A patient's wife asks the nurse why her husband did not receive the clot busting
juices b. pureed meat c. scrambled eggs d. fortified milkshakes Correct Answer: C
medication (tPA) she has been reading about. Her husband is diagnosed with a hemorrhagic stroke. What should the nurse respond? a. He didn't arrive within the time frame for that therapy b. Not every is eligible for this drug. Has he had surgery lately? c. You should discuss the treatment of your husband with your doctor d. The medication you are talking about dissolves clots and could cause more bleeding in your husband's head
Correct Answer: D
- To promote communication during rehabilitation of the patient with aphasia, an
- A patient with right hemisphere stroke has a nursing diagnosis of unilateral neglect
appropriate nursing intervention is to: a. use gestures, pictures, and music to stimulate patient responses b. talk about activities of daily living (ADLs) that are familiar to the patient c. structure statements so that patient does not have to respond verbally d. use flashcards with simple words and pictures to promote language recall Correct Answer: B
related to sensory perceptual deficits. During the patient's rehabilitation, it is important for the nurse to: a. avoid positioning the patient on the affected side b. place all objects for care on the patient's unaffected side c. teach the patient to care consciously for the affected side d. protect the affected side from injury with pillows and supports Correct
Answer: C
- A patient with a stroke has a right sided hemiplegia. The nurse prepares family
members to help control behavior changes seen with this type of stroke by teaching them to: a. ignore undesirable behaviors manifested by the patient b. provide directions to the patient verbally in small steps c. distract the patient from inappropriate emotional responses d. supervise all activities before allowing the patient to pursue them
