NCLEX Stroke
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
The answer is A.
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
The answer is A.
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.
The answer is C.
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.
The answer is B. Because the patient has weakness on the right side and dysphagia the nurse should regularly check for pouching of food in the right cheek. Pouching of food in the cheek can lead to aspiration or choking. The HOB should be >30', liquids thickened per MD order, and the patient should tuck in the chin to the chest while swallowing.
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
The answer is B. Scores on the NIH stroke scale range from 0 to 42, with 0 (no stroke symptoms) and 21-42 (severe stroke symptoms).
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
The answer is A.
The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack).Which characteristics are associated with this condition? Select all that apply. 1. The client is aphasic. 2. The client has weakness on the right side of the body. 3. The client has complete bilateral paralysis of the arms and legs. 4. The client has weakness on the right side of the face and tongue. 5. The client has lost the abilityto move the right arm but is able to walk independently. 6. The client has lost the ability to ambulate independently but is able to feed and bathe himself or herself without assistance
ANSWER: 1, 2, 4 Rationale: Hemiparesis is a weakness of one side of the body that may occur after a stroke. It involves weakness of the face and tongue, arm, and leg on one side. These clients are also aphasic: unable to discriminate words and letters. They are generally very cautious and get anxious when attempting a new task. Complete bilateral paralysis does not occur in hemiparesis. The client with right-sided hemiparesis has weakness of the right arm and leg and needs assistance with feeding, bathing, and ambulating. ---------------------------------------------- Test-Taking Strategy: Focus on the subject, right-sided hemiparesis. Recalling that hemiparesis indicates weakness on one side of the body and focusing on the subject will direct you to the correct option. Also, noting the word complete in the question will assist you in answering correctly.
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? 1. Gets angry with family if they interrupt a task 2. Experiences bouts of depression and irritability 3. Has difficulty with using modified feeding utensils 4. Consistently uses adaptive equipment in dressing self
ANSWER: 4 Rationale: Clients are evaluated as coping successfully with lifestyle changes after a stroke if they make appropriate lifestyle alterations, use the assistance of others, and have appropriate social interactions. Options 1 and 2 are not adaptive behaviors; option 3 indicates a not yet successful attempt to adapt. ---------------------------------------------- Test-Taking Strategy: Note the strategic word, most, and focus on the subject, indications that a client who has had a stroke is adapting most successfully. Options 1 and 2 are behaviors that may be expected in the client with a stroke, but they are not adaptive responses. Instead, they are a result of the insult to the brain. Options 3 and 4 indicate that the client is trying to adapt, but the correct option has the best outcome.
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? 1. "We need to discourage him from wearing eyeglasses." 2. "We need to place objects in his impaired field of vision." 3. "We need to approach him from the impaired field of vision." 4. "We need to remind him to turn his head to scan the lost visual field."
ANSWER: 4 Rationale: Homonymous hemianopsia is loss of half of the visual field. The client with homonymous hemianopsia should have objects placed in the intact field of vision, and the nurse also should approach the client from the intact side. The nurse instructs the client to scan the environment to overcome the visual deficit and does client teaching from within the intact field of vision. The nurse encourages the use of personal eyeglasses, if they are available. ------------------------------------------------ Test-Taking Strategy: Focus on the subject, homonymous hemianopsia. Eliminate options 2 and 3 first because they are comparable or alike. Recalling the definition of homonymous hemianopsia will direct you easily to the correct option
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.
The answer is A. It is important to watch for neglect syndrome. This tends to happen in right side brain damage. The patient ignores the left side of the body in this condition. The nurse needs to remind the patient to use and touch both sides of the body daily and that the patient must make a conscious effort to do so.
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
The answer is B. If a patient is in uncontrolled a-fib they are at risk for clot formation within the heart chambers. This clot can leave the heart and travel to the brain. Hence, an ischemic embolism type stroke can occur. An ischemic thrombosis type stroke is where a clot forms within the artery wall of the neck or brain.
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
The answer is B. The cerebellum is important for coordination and balance.
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.
The answer is C. A hemorrhagic stroke occurs when bleeding in the brain happens due to a break in a blood vessel. Risk factors for a hemorrhagic stroke is uncontrolled hypertension, history of brain aneurysm, old age (due to aging blood vessels.) All the other options are at risk for an ischemic type of stroke.
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
The answer is C. Hemianopia is limited vision in half of the visual field. The patient needs to scan the room from side to side to prevent injury.
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
The answer is C. tPA dissolves the clot causing the blockage in stroke by activating the protein that causes fibrinolysis. It should be given within 3 hours after the onset of stroke symptoms. It can be given 3 to 4.5 hours after onset IF the patient meets strict criteria. It is used for acute ischemia stroke, NOT hemorrhagic!!
You're 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
The answer is D.
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
The answer is D. The occipital lobe is responsible for vision and color perception.
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
The answer is D. The temporal lobe is responsible for hearing, learning, and feelings/emotions
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
The answers are A, C, D, F, and H. Patients who have left side brain damage will have aphasia, be AWARE of their limitations, impaired math skills, issues with seeing on the right side, no deficit in memory, depression/anger, cautious, and agraphia. All the other options are found in right side brain injury.
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
The answers are A, D, and E. These risk factors are modifiable in that the patient can attempt to change them to prevent another stroke in the future. The other risk factors are NOT modifiable.
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.
The answers are B and D. Options A and C are CORRECT statements about TIAs. However, option B is wrong because TIAs produce signs and symptoms that can last a few minutes to hours and resolve (NOT several weeks to months). Option D is wrong be TIAs do require medical treatment.
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.
The answers are B and D. Patients who are experiencing signs and symptoms of a hemorrhagic stroke, who have a BP for >185/110, and has received heparin or any other anticoagulants etc. are NOT a candidate for tPA. tPA is only for an ischemic stroke.
A patient has right side brain damage from a stroke. Select all the signs and symptoms that occur 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
The answers are B, D, F, and G. Patients who have right side brain damage will have LEFT side hemiplegia (opposite side), confused on date, time, and place, unilateral neglect (left side neglect), DENIAL about limitations, be impulsive, and have a short attention span. Agraphia, right side hemiplegia, aware of limitations, and aphasia occur in a LEFT SIDE brain injury.
You're 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.
The answers are C and D. Patients with expressive aphasia can understand spoken words but can't respond back effectively or at all. Therefore be patient, let them speak, be direct and ask simple questions that require a simple response, and communicate with a dry erase board etc.
