STROKE- NCLEX Exam Questions With Correct Answers.
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Course
STROKE- NCLEX
Institution
STROKE- NCLEX
STROKE- NCLEX Exam Questions With
Correct Answers.
Difficulty swallowing
The patient's inability to swallow without difficulty would cause the nurse the most concern.
Difficulty in swallowing, hoarseness or other signs of cranial nerve dysfunction must be
assessed. The nurse focuses on assessm...
STROKE- NCLEX Exam Questions With
Correct Answers.
Difficulty swallowing
The patient's inability to swallow without difficulty would cause the nurse the most concern.
Difficulty in swallowing, hoarseness or other signs of cranial nerve dysfunction must be
assessed. The nurse focuses on assessment of the following cranial nerves: facial (VII), vagus
(X), spinal accessory (XI), and hypoglossal (XII). Some edema in the neck after surgery is
expected; however, extensive edema and hematoma formation can obstruct the airway.
Emergency airway supplies, including those needed for a tracheostomy, must be available. The
patient's neck pain and mild BP elevation need addressing but would not cause the nurse the
most concern. Hypotension is avoided to prevent cerebral ischemia and thrombosis.
Uncontrolled hypertension may precipitate cerebral hemorrhage, edema, hemorrhage at the
surgical incision, or disruption of the arterial reconstruction. - answer✔✔The nurse is caring for
a patient with a history of transient ischemic attacks (TIAs) and moderate carotid stenosis who
has undergone a carotid endarterectomy. Which of the following postoperative findings would
cause the nurse the most concern?
a) Blood pressure (BP): 128/86 mm Hg
b) Neck pain: 3/10 (0 to 10 pain scale)
c) Mild neck edema
d) Difficulty swallowing
She is taking coumadin.
, EXAM STUDY MATERIALS 8/7/2024 11:29 AM
To be eligible for thrombolytic therapy, the client cannot be taking coumadin. Initiation of
thrombolytic therapy must be within 3 hours in clients with ischemic stroke. The client is not
eligible for thrombolytic therapy if she has had surgery within 14 days. Digoxin and labetelol do
not prohibit thrombolytic therapy. - answer✔✔An emergency department nurse is interviewing a
client with signs of an ischemic stroke that began 2 hours ago. The client reports that she had a
cholecystectomy 6 weeks ago and is taking digoxin, coumadin, and labetelol. This client is not
eligible for thrombolytic therapy for which of the following reasons?
a) She is not within the treatment time window.
b) She had surgery 6 weeks ago.
c) She is taking digoxin.
d) She is taking coumadin.
Homonymous hemianopsia
Homonymous hemianopsia (loss of half of the visual field) may occur from stroke and may be
temporary or permanent. Double vision is documented as diplopia. Nystagmus is ocular bobbing
and may be seen in multiple sclerosis. Anisocoria is unequal pupils. - answer✔✔Which
disturbance results in loss of half of the visual field?
a) Anisocoria
b) Homonymous hemianopsia
c) Nystagmus
d) Diplopia
, EXAM STUDY MATERIALS 8/7/2024 11:29 AM
Perform a vision field assessment.
The nurse should perform a vision field assessment to evaluate the client forhemianopia. This
finding could indicate damage to the visual area of the brain as a result of evolving CVA.
Repositioning the tray and assisting with feeding would not be the best nursing action until new
finding has been evaluated. Hemianopia can be associated with a CVA but, when presenting as a
new finding, should be evaluated and reported immediately. (less) - answer✔✔A client with a
cerebrovascular accident (CVA) is having difficulty with eating food on the plate. Which is the
best nursing action to be taken?
a) Reposition the tray and plate.
b) Perform a vision field assessment.
c) Know this is a normal finding for CVA.
d) Assist the client with feeding.
Transient ischemic attack
A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment caused by a
temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour; some
continue for as long as 1 day. When the symptoms terminate, the client resumes his or her
presymptomatic state. The symptoms do not describe a left- or right-sided stroke or a cerebral
aneurysm. - answer✔✔A client is hospitalized when they present to the Emergency Department
with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had
resolved and the client was back to their presymptomatic state. The nurse caring for the client
knows that the probable cause of the neurologic deficit was what?
a) Cerebral aneurysm
, EXAM STUDY MATERIALS 8/7/2024 11:29 AM
b) Transient ischemic attack
c) Left-sided stroke
d) Right-sided stroke
Agnosia
Auditory agnosia is failure to recognize significance of sounds. Agraphia refers to disturbances
in writing intelligible words. Apraxia refers to inability to perform previously learned purposeful
motor acts on a voluntary basis. Perseveration is the continued and automatic repetition of an
activity, word, or phrase that is no longer appropriate. - answer✔✔Which of the following terms
refer to the failure to recognize familiar objects perceived by the senses?
a) Agnosia
b) Perseveration
c) Apraxia
d) Agraphia
"Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the
degree of blockage, and the availability of collateral circulation."
Clinical manifestations following a stroke are highly variable and depend on the area of the
cerebral cortex and the affected hemisphere, the degree of blockage (total, partial), and the
presence or absence of adequate collateral circulation. (Collateral circulation is circulation
formed by smaller blood vessels branching off from or near larger occluded vessels.) Clinical
manifestations of a stroke do not depend on the cardiovascular health of the client or how
quickly the clot can be dissolved. Clinical manifestations of a stroke are not "general" but
individual. - answer✔✔During a class on stroke, a junior nursing student asks what the clinical
manifestations of stroke are. What would be the instructor's best answer?
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