1. Which of the following is the most critical initial assessment finding in a patient with a suspected stroke?
o A. Blood pressure
o B. Glasgow Coma Scale score
o C. Pupillary response
o D. Oxygen saturation
o Answer: B. Glasgow Coma Scale score
Rationale: The Glasgow Coma Scale (GCS) assess...
1. Which of the following is the most critical initial assessment finding in a patient with
a suspected stroke?
o A. Blood pressure
o B. Glasgow Coma Scale score
o C. Pupillary response
o D. Oxygen saturation
o Answer: B. Glasgow Coma Scale score
Rationale: The Glasgow Coma Scale (GCS) assesses the level of consciousness
and neurological function, which is crucial for determining the severity of a
stroke.
2. A patient presents with sudden weakness in the right arm and slurred speech.
Which nursing action is the priority?
o A. Administer oxygen
o B. Check blood glucose levels
o C. Perform a neurological assessment
o D. Notify the physician
o Answer: C. Perform a neurological assessment
Rationale: A quick neurological assessment will help identify the severity of the
situation and guide immediate interventions.
3. What is the primary goal of administering anticoagulant therapy in a patient with a
history of stroke?
o A. Reduce pain
o B. Prevent further clot formation
o C. Improve circulation
o D. Increase blood pressure
o Answer: B. Prevent further clot formation
Rationale: Anticoagulants are used to prevent the formation of new clots and
reduce the risk of another stroke.
4. A nurse is caring for a patient with increased intracranial pressure (ICP). Which of
the following assessments indicates worsening ICP?
o A. Decreased heart rate
o B. Vomiting
o C. Increased respiratory rate
o D. Unequal pupil size
o Answer: D. Unequal pupil size
Rationale: Unequal pupils may indicate brain herniation or increased pressure
affecting cranial nerves.
5. Which of the following is an appropriate nursing intervention for a patient
experiencing a seizure?
o A. Place a padded tongue blade in the patient's mouth
o B. Hold the patient down to prevent injury
o C. Move objects away from the patient
o D. Restrain the patient during the seizure
, o Answer: C. Move objects away from the patient
Rationale: Ensuring a safe environment by removing potentially harmful objects
is crucial during a seizure.
6. A patient with a head injury is being monitored for signs of neurological
deterioration. Which finding should the nurse report immediately?
o A. Increased drowsiness
o B. Complaints of headache
o C. Clear nasal discharge
o D. Temperature of 100°F
o Answer: A. Increased drowsiness
Rationale: Increased drowsiness can indicate a decline in neurological status and
requires immediate intervention.
7. What should the nurse prioritize when caring for a patient with Guillain-Barré
syndrome?
o A. Pain management
o B. Respiratory function monitoring
o C. Skin integrity
o D. Nutritional support
o Answer: B. Respiratory function monitoring
Rationale: Guillain-Barré syndrome can lead to respiratory muscle weakness;
monitoring respiratory function is critical.
8. A patient is diagnosed with multiple sclerosis (MS). Which symptom would the
nurse expect to find in this patient?
o A. Hemiplegia
o B. Visual disturbances
o C. Bradycardia
o D. Hypoglycemia
o Answer: B. Visual disturbances
Rationale: Visual disturbances are common in MS due to demyelination affecting
the optic nerve.
9. Which assessment finding in a patient with Parkinson's disease would the nurse
anticipate?
o A. Rapid speech
o B. Tremors at rest
o C. Widened gait
o D. Hyperreflexia
o Answer: B. Tremors at rest
Rationale: Resting tremors are a classic sign of Parkinson's disease.
10. A nurse is providing discharge teaching for a patient with a recent diagnosis of
amyotrophic lateral sclerosis (ALS). What is the most important teaching point?
o A. Emphasize the need for regular exercise
o B. Discuss advance directives and end-of-life care
o C. Recommend a high-fiber diet
o D. Encourage smoking cessation
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