1) 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 of hypertension. d) The patient has atrial fibrillation and takes warfarin (Coumadin). 2) The nurse has instructed the family of a client with stroke (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.” 3) 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 4) 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) Raise the head of the bed to a sitting position. 5) 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. 6) . 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. 7) 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) 8) 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 central nervous system (CNS) depressants to lightly sedate the patient. d) Continue the exercises because they are necessary to maintain musculoskeletal function. 9) Regular oral hygiene is essential for a 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. 10) 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) Lie in bed with the unaffected side toward the door. 11) What is the expected outcome of thrombolytic drug therapy for stroke? a) Increased vascular permeability. b) Vasoconstriction. c) Dissolved emboli. d) Prevention of hemorrhage. 12) The nurse can assist 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 13) 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? a) The patient has dysphasia.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. 14) When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis a) When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis 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. 15) 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? a) Keep head of bed elevated at least 30 degrees. b) Infuse normal saline intravenously at 75 mL/hr. c) Administer tissue plasminogen activator (tPA) per protocol. d) Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg.

Stroke Review

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