Neurologic Disorders

Question 1

1. Select the main structures below that play a role with altering intracranial pressure:
   A. Brain
   B. Neurons
   C. Cerebrospinal Fluid
   D. Blood
   E. Periosteum
   F. Dura mater

Answer 1

A,C,D

Question 2

The Monro-Kellie hypothesis explains the compensatory relationship among the structures in the skull that play a role with intracranial pressure. Which of the following are NOT compensatory mechanisms performed by the body to decrease intracranial pressure naturally? Select all that apply:
A. Shifting cerebrospinal fluid to other areas of the brain and spinal cord
B. Vasodilation of cerebral vessels
C. Decreasing cerebrospinal fluid production
D. Leaking proteins into the brain barrier

Answer 2

B,D

Question 3

A patient is being treated for increased intracranial pressure. Which activities below should the patient avoid performing?
A. Coughing
B. Sneezing
C. Talking
D. Valsalva maneuver
E. Vomiting
F. Keeping the head of the bed between 30- 35 degrees

Answer 3

A,B,D,E

Question 4

A patient is experiencing hyperventilation and has a PaCO2 level of 52. The patient has an ICP of 20 mmHg. As the nurse you know that the PaCO2 level will?
A. cause vasoconstriction and decrease the ICP
B. promote diuresis and decrease the ICP
C. cause vasodilation and increase the ICP
D. cause vasodilation and decrease the ICP

Answer 4

C

Question 5

You’re providing education to a group of nursing students about ICP. You explain that when cerebral perfusion pressure falls too low the brain is not properly perfused and brain tissue dies. A student asks, “What is a normal cerebral perfusion pressure level?” Your response is:
A. 5-15 mmHg
B. 60-100 mmHg
C. 30-45 mmHg
D. >160 mmHg

Answer 5

B

Question 6

Which patient below is at MOST risk for increased intracranial pressure?
A. A patient who is experiencing severe hypotension.
B. A patient who is admitted with a traumatic brain injury.
C. A patient who recently experienced a myocardial infarction.
D. A patient post-op from eye surgery.

Answer 6

B

Question 7

A patient with increased ICP has the following vital signs: blood pressure 99/60, HR 65, Temperature 101.6 ‘F, respirations 14, oxygen saturation of 95%. ICP reading is 21 mmHg. Based on these findings you would?
A. Administered PRN dose of a vasopressor
B. Administer 2 L of oxygen
C. Remove extra blankets and give the patient a cool bath
D. Perform suctioning

Answer 7

C

Question 8

A patient has a ventriculostomy. Which finding would you immediately report to the doctor?
A. Temperature 98.4 ‘F
B. CPP 70 mmHg
C. ICP 24 mmHg
D. PaCO2 35

Answer 8

C

Question 9

External ventricular drains monitor ICP and are inserted where?
A. Subarachnoid space
B. Lateral Ventricle
C. Epidural space
D. Right Ventricle

Answer 9

B

Question 10

Which of the following is contraindicated in a patient with increased ICP?
A. Lumbar puncture
B. Midline position of the head
C. Hyperosmotic diuretics
D. Barbiturates medications

Answer 10

A

Question 11

You’re collecting vital signs on a patient with ICP. The patient has a Glascoma Scale rating of 4. How will you assess the patient’s temperature?
A. Rectal
B. Oral
C. Axillary

Answer 11

A

Question 12

A patient who experienced a cerebral hemorrhage is at risk for developing increased ICP. Which sign and symptom below is the EARLIEST indicator the patient is having this complication?
A. Bradycardia
B. Decerebrate posturing
C. Restlessness
D. Unequal pupil size

Answer 12

C

Question 13

Select all the signs and symptoms that occur with increased ICP:
A. Decorticate posturing
B. Tachycardia
C. Decrease in pulse pressure
D. Cheyne-stokes
E. Hemiplegia
F. Decerebrate posturing

Answer 13

A,D,E,F

Question 14

You’re maintaining an external ventricular drain. The ICP readings should be?
A. 5 to 15 mmHg
B. 20 to 35 mmHg
C. 60 to 100 mmHg
D. 5 to 25 mmHg

Answer 14

A

Question 15

. Which patient below with ICP is experiencing Cushing’s Triad? A patient with the following:
A. BP 150/112, HR 110, RR 8
B. BP 90/60, HR 80, RR 22
C. BP 200/60, HR 50, RR 8
D. BP 80/40, HR 49, RR 12

Answer 15

C

Question 16

The patient has a blood pressure of 130/88 and ICP reading of 12. What is the patient’s cerebral perfusion pressure, and how do you interpret this as the nurse?
A. 90 mmHg, normal
B. 62 mmHg, abnormal
C. 36 mmHg, abnormal
D. 56 mmHg, normal

Answer 16

A

Question 17

According to question 16, the patient’s blood pressure is 130/88. What is the patient’s mean arterial pressure (MAP)?
A. 42
B. 74
C. 102
D. 88

Answer 17

C

Question 18

During the assessment of a patient with increased ICP, you note that the patient’s arms are extended straight out and toes pointed downward. You will document this as:
A. Decorticate posturing
B. Decerebrate posturing
C. Flaccid posturing

Answer 18

B

Question 19

While positioning a patient in bed with increased ICP, it important to avoid?
A. Midline positioning of the head
B. Placing the HOB at 30-35 degrees
C. Preventing flexion of the neck
D. Flexion of the hips

Answer 19

D

Question 20

During the eye assessment of a patient with increased ICP, you need to assess the oculocephalic reflex. If the patient has brain stem damage what response will you find?
B. The eyes will move in the opposite direction as the head is moved side to side.
C. The eyes will roll back as the head is moved side to side.
D. The eyes will be in a fixed mid-line position as the head is moved side to side.

Answer 20

D

Question 21

A patient is receiving Mannitol for increased ICP. Which statement is INCORRECT about this medication?
A. Mannitol will remove water from the brain and place it in the blood to be removed from the body.
B. Mannitol will cause water and electrolyte reabsorption in the renal tubules.
C. When a patient receives Mannitol the nurse must monitor the patient for both fluid volume overload and depletion.
D. Mannitol is not for patients who are experiencing anuria.

Answer 21

B

Question 22

What assessment finding requires immediate intervention if found while a patient is receiving Mannitol?
A. An ICP of 10 mmHg
B. Crackles throughout lung fields
C. BP 110/72
D. Patient complains of dry mouth and thirst

Answer 22

B

Question 23

Which term describes the pressure required to perfuse the tissues of the brain?
a. mean arterial pressure
b. intracranial pressure
c. cerebral perfusion pressure
d. blood pressure

Answer 23

C

Question 24

Which THREE are the components of the cranium and spinal cord which can be decreased as a result of compensation in raised intracranial pressure?
a. water
b. blood
c. cerebrospinal fluid
d. brain tissue

Answer 24

B,C,D

Question 25

When intracranial pressure is at such a point when compensation is no longer possible, the brain is herniated and displaced into any available space. This is known as ______.
a. cardiac arrest
b. coning
c. brain stem death
d. Cushing’s triad

Answer 25

B

Question 26

Cerebral oedema caused by increased permeability of endothelial cells allowing fluid to escape into the extra cellular space is known as ______.
a. vasogenic
b. cytotoxic
c. obstructive
d. interstitial

Answer 26

A

Question 27

Which of the following is NOT a criteria for the definition of a coma?
a. absence of behavioural awareness for 2 hours
b. no voluntary movement
c. absence of a sleep–wake cycle
d. no response to pain, light or sound

Answer 27

A

Question 28

A patient with spinal injury presents with sweating and vasodilation above the level of injury with hypertension and bradycardia. This could be ______.
a. spinal shock
b. clonus
c. neurogenic shock
d. autonomic dysreflexia

Answer 28

D

Question 29

Which condition is attributed to an imbalance of either low levels of inhibitory neurotransmitters or high levels of excitatory transmitters in cerebral neurones?
a. a seizure due to neurological temporary malfunction
b. encephalitis
c. meningitis
d. epilepsy

Answer 29

D

Question 30

Which one of the following is the main pathophysiology of multiple sclerosis?
a. decreased level of dopamine in the brain
b. deposits of amyloid protein causing neurofibrillary tangles
c. autoimmune destruction of the myelin sheath of nerve cells
d. failure of mitochondria

Answer 30

C

Question 31

A patient is admitted with uncontrolled atrial fibrillation. The patient’s medication history includes vitamin D supplements and calcium. What type of stroke is this patient at MOST risk for?
A. Ischemic thrombosis
B. Ischemic embolism
C. Hemorrhagic
D. Ischemic stenosis

Answer 31

B

Question 32

Which patient below is at most risk for a hemorrhagic stroke?
A. A 65 year old male patient with carotid stenosis.
B. A 89 year old female with atherosclerosis.
C. A 88 year old male with uncontrolled hypertension and a history of brain aneurysm repair 2 years ago.
D. A 55 year old female with atrial flutter.

Answer 32

C

Question 33

You’re educating a patient about transient ischemic attacks (TIAs). Select all the options that are incorrect about this condition:
A. TIAs are caused by a temporary decrease in blood flow to the brain.
B. TIAs produce signs and symptoms that can last for several weeks to months.
C. A TIAs is a warning sign that an impending stroke may occur.
D. TIAs don’t require medical treatment.

Answer 33

B,D

Question 34

A patient who suffered a stroke one month ago is experiencing hearing problems along with issues learning and showing emotion. On the MRI what lobe in the brain do you expect to be affected?
A. Frontal lobe
B. Occipital lobe
C. Parietal lobe
D. Temporal

Answer 34

D

Question 35

A patient’s MRI imaging shows damage to the cerebellum a week after the patient suffered a stroke. What assessment findings would correlate with this MRI finding?
A. Vision problems
B. Balance impairment
C. Language difficulty
D. Impaired short-term memory

Answer 35

B

Question 36

A patient is demonstrating signs and symptoms of stroke. The patient reports loss of vision. What area of the brain do you suspect is affected based on this finding?
A. Brain stem
B. Hippocampus
C. Parietal lobe
D. Occipital lobe

Answer 36

D

Question 37

A patient has right side brain damage from a stroke. Select all the signs and symptoms that occurs with this type of stroke:
A. Right side hemiplegia
B. Confusion on date, time, and place
C. Aphasia
D. Unilateral neglect
E. Aware of limitations
F. Impulsive
G. Short attention span
H. Agraphia

Answer 37

B,D,F,G

Question 38

You’re educating a group of nursing students about left side brain damage. Select all the signs and symptoms noted with this type of stroke:
A. Aphasia
B. Denial about limitations
C. Impaired math skills
D. Issues with seeing on the right side
E. Disoriented
F. Depression and anger
G. Impulsive
H. Agraphia

Answer 38

A,C,D,F,H

Question 39

During discharge teaching for a patient who experienced a mild stroke, you are providing details on how to eliminate risk factors for experiencing another stroke. Which risk factors below for stroke are modifiable?
A. Smoking
B. Family history
C. Advanced age
D. Obesity
E. Sedentary lifestyle

Answer 39

A,D,E

Question 40

Your patient who had a stroke has issues with understanding speech. What type of aphasia is this patient experiencing and what area of the brain is affected?
A. Expressive; Wernicke’s area
B. Receptive, Broca’s area
C. Expressive; hippocampus
D. Receptive; Wernicke’s area

Answer 40

D

Question 41

Your patient has expressive aphasia. Select all the ways to effectively communicate with this patient?
A. Fill in the words for the patient they can’t say.
B. Don’t repeat questions.
C. Ask questions that require a simple response.
D. Use a communication board.
E. Discourage the patient from using words.

Answer 41

C,D

Question 42

While conversing with a patient who had a stroke six months ago, you note their speech is hard to understand and slurred. This is known as:
A. Dysarthria
B. Apraxia
C. Alexia
D. Dysphagia

Answer 42

A

Question 43

You’re reading the physician’s history and physical assessment report. You note the physician wrote that the patient has apraxia. What assessment finding in your morning assessment correlates with this condition?
A. The patient is unable to read.
B. The patient has limited vision in half of the visual field.
C. The patient is unable to wink or move his arm to scratch his skin.
D. The patient doesn’t recognize a pencil or television.

Answer 43

C

Question 44

You need to obtain informed consent from a patient for a procedure. The patient experienced a stroke three months ago. The patient is unable to sign the consent form because he can’t write. This is known as what:
A. Agraphia
B. Alexia
C. Hemianopia
D. Apraxia

Answer 44

A

Question 45

You’re assessing your patient’s pupil size and vision after a stroke. The patient says they can only see half of the objects in the room. You document this finding as:
A. Hemianopia
B. Opticopsia
C. Alexia
D. Dysoptic

Answer 45

A

Question 46

A patient who has hemianopia is at risk for injury. What can you educate the patient to perform regularly to prevent injury?
A. Wearing anti-embolism stockings daily
B. Consume soft foods and tuck in chin while swallowing
C. Scanning the room from side to side frequently
D. Muscle training

Answer 46

C

Question 47

You receive a patient who is suspected of experiencing a stroke from EMS. You conduct a stroke assessment with the NIH Stroke Scale. The patient scores a 40. According to the scale, the result is:
A. No stroke symptoms
B. Severe stroke symptoms
C. Mild stroke symptoms
D. Moderate stroke symptoms

Answer 47

B

Question 48

In order for tissue plasminogen activator (tPA) to be most effective in the treatment of stroke, it must be administered?
A. 6 hours after the onset of stroke symptoms
B. 3 hours before the onset of stroke symptoms
C. 3 hours after the onset of stroke symptoms
D. 12 hours before the onset of stroke symptoms

Answer 48

C

Question 49

Which patients are NOT a candidate for tissue plasminogen activator (tPA) for the treatment of stroke?
A. A patient with a CT scan that is negative.
B. A patient whose blood pressure is 200/110.
C. A patient who is showing signs and symptoms of ischemic stroke.
D. A patient who received Heparin 24 hours ago.

Answer 49

B,D

Question 50

You’re assisting a patient who has right side hemiparesis and dysphagia with eating. It is very important to:
A. Keep the head of bed less than 30′.
B. Check for pouching of food in the right cheek.
C. Prevent aspiration by thinning the liquids.
D. Have the patient extend the neck upward away from the chest while eating.

Answer 50

B

Question 51

A patient has experienced right side brain damage. You note the patient is experiencing neglect syndrome. What nursing intervention will you include in the patient’s plan of care?
A. Remind the patient to use and touch both sides of the body daily.
B. Offer the patient a soft mechanical diet with honey thick liquids.
C. Ask direct questions that require one word responses.
D. Offer the bedpan and bedside commode every 2 hours.

Answer 51

A

Question 52

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information would be of most concern to the nurse?
A. The patient’s pulse rate is 102 beats per minute.
B. The patient has difficulty speaking.
C. The patient’s blood pressure is 144/86 mmHg.
D. There is fine crackles at the lung bases.

Answer 52

B

Question 53

A patient in the emergency department complaining of 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?
A. The patient’s speech is slurring and is difficult to understand.
B. The patient’s latest blood pressure reading is 140/90mm.
C. The patient takes a diuretic because of a history ofhypertension.
D. The patient has atrial fibrillation and takes warfarin (Coumadin).

Answer 53

D

Question 54

The nurse has instructed the family of a client withstroke(brain attack) who has homonymous hemianopsia about measures to help the client overcome the deficit. Which statement suggests that the family understands the measures to use when caring for the client?
A. “We need to discourage him from wearing eyeglasses.”
B. “We need to place objects in his impaired field of vision.”
C. “We need to approach him from the impaired field of vision.”
D. “We need to remind him to turn his head to scan the lost visual field.”

Answer 54

D

Question 55

The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully?
A. Gets angry with family if they interrupt a task
B. Experiences bouts of depression and irritability
C. Has difficulty with using modified feeding utensils
D. Consistently uses adaptive equipment in dressing self

Answer 55

D

Question 56

A newly admitted patient diagnosed with right-sided brain stroke has a nursing diagnosis of disturbed visual sensory perception related to homonymous hemianopsia. Early in the care of the patient, what should the nurse do?
A. Place objects on the 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.

Answer 56

A

Question 57

Four days following a stroke, a patient is to start oral fluids and feedings. Before feeding the patient, what should the nurse do first?
A. Check the patient’s gag reflex.
B. Order a soft diet for the patient.
C. Raise the head of the bed to a sitting position.
D. Evaluate the patient’s ability to swallow small amounts of crushed ice or ice water.

Answer 57

A

Question 58

The rehabilitation nurse assesses the patient, caregiver, and family before planning the rehabilitation program for this patient. What needs to be included in this assessment (select all that apply)?
A. Cognitive status of the family
B. Patient resources and support
C. Rehabilitation potential of the patient
D. Body strength remaining after the stroke
E. Physical status of body systems affected by the stroke
F. Patient and caregiver expectations of the rehabilitation

Answer 58

A,D,E,F

Question 59

What is an appropriate nursing intervention to promote communication during the patient’s rehabilitation with aphasia?
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 the patient does not have to respond verbally.
D. Use flashcards with simple words and pictures to promote recall of language.

Answer 59

D

Question 60

A female patient has left-sided hemiplegia following an ischemic stroke that she experienced four days earlier. How should the nurse best promote the health of the patient’s integumentary system?
A. Position the patient on her weak side the majority of the time.
B. Alternate the patient’s positioning between supine and side-lying.
C. Avoid the use of pillows to promote independence in positioning.
D. Establish a schedule for the massage of areas where skin breakdown emerges.

Answer 60

B

Question 61

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)?
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).

Answer 61

C

Question 62

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

Answer 62

B

Question 63

A male patient who has a 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?
A. Interrupted family processes related to effects of illness of a family member
B. Situational low self-esteem related to increasing dependence on the 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

Answer 63

C

Question 64

A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will be included in the care plan?
A. Apply intermittent pneumatic compression stockings.
B. Assist in dangling on the edge of the bed and assessing for dizziness.
C. Encourage patient to cough and deep breathe every 4 hours.
D. Insert an oropharyngeal airway to prevent airway obstruction.

Answer 64

A

Question 65

A 58-year-old patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should
A. use a calm voice to ask the patient to stop the crying behavior.
B. explain to the family that depression is usual following a stroke.
C. have the family members leave the patient alone for a few minutes.
D. teach the family that emotional outbursts are common after strokes.

Answer 65

D

Question 66

Of the following patients, the nurse recognizes that the one with the highest risk for a stroke is a(n)
A. obese 45-year-old Native American.
B. 35-year-old Asian American woman who smokes.
C. 32-year-old white woman taking oral contraceptives.
D. 65-year-old African American man with hypertension.

Answer 66

D

Question 67

A patient comes to the emergency department immediately after experiencing numbness of the face and an inability to speak. Still, while the patient awaits examination, the symptoms disappear, and the patient requests discharge. Why should the nurse emphasize that it is vital for the patient to be treated before leaving?
A. The patient has probably experienced an asymptomatic lacunar stroke.
B. The symptoms are likely to return and progress to worsening neurological 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 cerebrovascular disease.

Answer 67

D

Question 68

A carotid endarterectomy is considered a treatment for a patient who has had several TIAs. What should the nurse explain to the patient about this surgery?
A. It involves intracranial surgery to join a superficial extracranial artery to an intracranial artery.
B. It is used to restore blood circulation to the brain following obstruction of a cerebral artery.
C. It involves removing an atherosclerotic plaque in the carotid artery to prevent an impending stroke.
D. It is used to open a stenosis in a carotid artery with a balloon and stent to restore cerebral circulation.

Answer 68

C

Question 69

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 a 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 significant arteries are occluded by thrombus formation around an atherosclerotic plaque

Answer 69

C

Question 70

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

Answer 70

C

Question 71

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)

Answer 71

A

Question 72

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

Answer 72

D

Question 73

An appropriate food for a patient with a stroke who has mild dysphagia is
A. fruit juices
B. pureed meat
C. scrambled eggs
D. fortified milkshakes

Answer 73

C

Question 74

A patient’s wife asks the nurse why her husband did not receive the clot-busting medication (tPA) she has been reading about. Her husband was diagnosed with a hemorrhagic stroke. What should the nurse respond?
A. He didn’t arrive within the time frame for that therapy
B. Not everyone 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

Answer 74

D

Question 75

The patient is being monitored long-term with a brain tissue oxygenation catheter. What range for the pressure of oxygen in brain tissue (PbtO2) will maintain cerebral oxygen supply and demand?
A. 55% to 75%
B. 20 to 40 mm Hg
C. 70 to 150 mm Hg
D. 80 to 100 mm Hg

Answer 75

B

Question 76

An unconscious patient with an increased ICP is on ventilatory support. The nurse notifies the health care provider when arterial blood gas (ABG) measurement results reveal what?
A. pH of 7.43
B. SaO2 of 94%
C. PaO2 of 70 mm Hg
D. PaCO2 of 35 mm Hg

Answer 76

C

Question 77

While the nurse performed a range of motion (ROM) on an unconscious patient with increased ICP and suspected of suffering from stroke, the patient experienced severe decerebrate posturing reflexes. What should the nurse do first?
A. Use restraints to protect the patient from injury.
B. Perform the exercises less frequently because posturing can increase ICP.
C. Administer centralnervous system(CNS) depressants to lightly sedate the patient.
D. Continue the exercises because they are necessary to maintain musculoskeletal function.

Answer 77

B

Question 78

What is a nursing intervention that is indicated for the patient with hemiplegia?
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 range of motion (ROM) of the affected limb with the unaffected limb

Answer 78

D

Question 79

Regular oral hygiene is essential for the client who has had a stroke. Which of the following nursing measures is not appropriate when providing oral hygiene?
A. Placing the client on the back with a small pillow under the head.
B. Keeping portable suctioning equipment at the bedside.
C. Opening the client’s mouth with a padded tongue blade.
D. Cleaning the client’s mouth and teeth with a toothbrush.

Answer 79

A

Question 80

In planning care for the client who has had a stroke, the nurse should obtain a history of the client’s functional status before the stroke because?
A. The rehabilitation plan will be guided by it.
B. Functional status before the stroke will help predict outcomes.
C. It will help the client recognize his physical limitations.
D. The client can be expected to regain much of his functioning.

Answer 80

A

Question 81

A nurse is teaching a client who had a stroke about adapting to a visual disability. Which does the nurse identify as the primary safety precaution to use?
A. Wear a patch over one eye.
B. Place personal items on the sighted side.
C. Lie in bed with the unaffected side toward the door.
D. Turn the head from side to side when walking.

Answer 81

D

Question 82

A client is experiencing mood swings after a stroke and often has episodes of tearfulness that are distressing to the family. Which is the best technique for the nurse to instruct family members when the client experiences a crying episode?
A. Sit quietly with the client until the episode is over.
B. Ignore the behavior.
C. Attempt to divert the client’s attention.
D. Tell the client that this behavior is unacceptable.

Answer 82

C

Question 83

The client who has had a stroke with residual physical handicaps becomes discouraged by his physical appearance. What approach to the client is best for the nurse to use to help the client overcome his negative self-concept? Select all that apply.
A. Helpfulness.
B. Charity.
C. Firmness.
D. Encouragement.
E. Patience.

Answer 83

D,E

Question 84

What is the expected outcome of thrombolytic drug therapy for stroke?
A. Increased vascular permeability.
B. Vasoconstriction.
C. Dissolved emboli.
D. Prevention of hemorrhage.

Answer 84

C

Question 85

A nursing assistant is providing care to a client with left-sided paralysis. Which of the following actions by the nursing assistant requires the nurse to offer further instruction?
A. Providing a passive range of motion exercises to the left extremities during the bed bath.
B. Elevating the foot of the bed to reduce edema.
C. Pulling up the client under the left shoulder when getting out of bed to a chair.
D. Putting high top tennis shoes on the client after bathing.

Answer 85

C

Question 86

Thenurse canassist the patient and the family in coping with the long term effects of a stroke by
A. informing family members that the patient will need assistance with almost all ADLs
B. explaining that the patient’s pre-stroke behavior will return as improvement progresses
C. encouraging the patient and family members to seek assistance from family therapy or stroke support groups
D. helping the patient and family understand the significance of residual stroke damage to promote problem-solving and planning

Answer 86

D

Question 87

Which type of stroke shows interrupted vessel integrity and bleeding that occurs into the brain tissue or into the subarachnoid space?
A. Embolic Stroke
B. Thrombotic Stroke
C. Ischemic Stroke
D. Hemorrhagic Stroke

Answer 87

D

Question 88

The nurse is teaching a group of older adults about transient ischemic attack (TIA). Which statement made by a participant indicates a need for further teaching regarding TIAs?
A. “There is a loss of central vision”
B. “A TIA is a warning sign for ischemic stroke.”
C. “Symptoms last less than 24 hours”
D. “A TIA of any kind is a medical emergency.”

Answer 88

A

Question 89

A patient in the emergency department (ED) has slurred speech, confusion, and visual problems, and has been having intermittent episodes of worsening symptoms. The symptoms have a gradual onset. The patient also has a history of hypertension and atherosclerosis. What does the nurse suspect that the patient is probably experiencing?
A. Embolic Stroke
B. Hemorrhagic Stroke
C. Thrombotic Stroke
D. Transient Ischemic Stroke

Answer 89

C

Question 90

A 70-year-old woman brought to the emergency department is diagnosed with acute ischemic stroke with a NIH Stroke Scale score of 20. A family member reports last seeing the patient as normal (LSN) 3.5 hours before evaluation. The patient has an INR of 1.4. The nurse anticipates that the patient will not be eligible for fibrinolytic therapy for which reason?
A. INR 1.4
B. Age older than 65 years
C. Female Gender
D. High NIH Stroke Scale Score

Answer 90

A

Question 91

A patient has been admitted to the hospital with symptoms of an embolic stroke. What etiologic factor in the patient’s history places the patient atparticularrisk for this type of stroke?
A. Atrial Fibrillation
B. Diabetes Mellitus
C. Aortic Aneurysm
D. Irritable Bowel Disease

Answer 91

A

Question 92

Which does the nurse teach the patient is a modifiable risk factor for stroke?
A. Age
B. Obesity
C. Gender
D. Family history of hypertension

Answer 92

B

Question 93

The nurse receives a patient in the emergency department (ED) who experienced a stroke. The patient is alert and requests something to eat from the nurse. Which is thebestaction the nurse can take?
A. Provide thickened fluids to the patient
B. Obtain a prescription to give intravenous fluids
C. Assess the swallowing ability of the patient
D. Assess the level of consciousness in the patient

Answer 93

C

Question 94

The patient is admitted with a diagnosis of stroke in the right cerebral hemisphere. Upon assessment, which primary deficit does the nurse expect to find?
A. Worsening aphasia
B. Impaired proprioception
C. Agraphia
D. Alexia

Answer 94

B

Question 95

Alteplase should be given within how many hours from the onset of symptoms of stroke?
A. 6
B. 4.5
C. 12
D. 1.5

Answer 95

B

Question 96

Abuse of which substance ismostlikely to result in a hemorrhagic stroke?
A. Heroin
B. Cocaine
C. Nicotine
D. Marijuana

Answer 96

B

Question 97

The nurse is caring for a patient one day after the patient experienced a stroke. The patient is fully alert and has weakness of the right side of the body. Which assessment finding indicates an increasing intracranial pressure (ICP)?
A. The patient is no longer oriented to place
B. The patient has developed urinary incontinence
C. The patient reports numbness of the right leg
D. The patient has a blood pressure of 90/62

Answer 97

A

Question 98

Which are risk factors for stroke? Select all that apply:
A. Smoking
B. High blood pressure
C. Previous stroke or transient ischemic attack (TIA)
D. Female Gender

Answer 98

A,B,C

Question 99

A patient is admitted with a stroke (brain attack). Which tool does the nurse use to facilitate a focused neurologic assessment of the patient?
A. Reflex hammer
B. National Institutes of Health Stroke Scale (NIHSS)
C. Intracanial pressure monitor
D. Mini-Mental State Examination (MMSE)

Answer 99

B