1. Answer: B.

Rationale: Small emboli can occur during carotid artery angioplasty and stenting, and the aphasia indicates a possible stroke during the procedure. Slightly elevated pulse rate and blood pressure are not unusual because of anxiety associated with the procedure. Fine crackles at the lung bases may indicate atelectasis caused by immobility during the procedure. The nurse should have the patient take some deep breaths.

  1. Answer: D.

Rationale: The use of warfarin has probably contributed to the intracerebral bleeding and remains a risk factor for further bleeding. Administration of vitamin K is needed to reverse the effects of the drug, especially if the patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient but has no immediate effect on the patient’s care. The blood pressure of 140/90mmHg indicates a need for ongoing monitoring but not for any rapid change in therapy. Slurred speech is consistent with a left-sided stroke, and no change in treatment is needed.

  1. Answer: D.

Rationale: Homonymous hemianopsia is the 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.

  1. Answer: D.

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 relevant social interactions. Options A and B are not adaptive behaviors; option C indicates an unsuccessful attempt to adapt.

  1. Answer: A.

Rationale: The presence of homonymous hemianopia in a patient with right hemisphere brain damage causes a loss of vision in the left field bilaterally. Early in the patient’s care, objects should be placed on the right side of the patient in the field of vision, and the nurse should approach the patient from the right side. Later in treatment, patients should be taught to turn the head, scan the environment, and approach the affected side to encourage head-turning. Eye patches are used if patients have diplopia (double vision).

  1. Answer: A.

Rationale: Usually, the speech therapist will have completed a swallowing study before a diet is ordered. The first step in providing oral feedings for a patient with a stroke is ensuring that the patient has an intact gag reflex because oral feedings will not be provided if the gag reflex is impaired. After placing the patient in an upright position, the nurse should then evaluate the patient’s ability to swallow ice chips or ice water.

  1. Answer: A, D, E, F

Rationale: The patient’s rehabilitation potential and expectations of the patient and caregiver related to the rehabilitation program will significantly impact planning and carrying out the rehabilitation plan. The other things the rehabilitation nurse will assess are the physical status of all the patient’s body systems, the presence of complications caused by the stroke or other chronic conditions, the cognitive status of the patient, and the family (including the patient and caregiver) resources and support.

  1. Answer: D.

Rationale: During rehabilitation, patients with aphasia need frequent, meaningful verbal stimulation that is relevant for them. Conversation by the nurse and family should address activities of daily living (ADLs) that are familiar to the patient. Gestures, pictures, and simple statements are more appropriate in the acute phase, when patients may be overwhelmed by verbal stimuli. The patient often perceives flashcards as childish and meaningless. Not responding verbally does not promote communication.

  1. Answer: B.

Rationale: A position change schedule should be established for stroke patients. An example is side-back-side, with a maximum duration of 2 hours for any position. The patient should be positioned on the weak or paralyzed side for only 30 minutes. Pillows may be used to facilitate positioning. Areas of skin breakdown should never be massaged.

  1. Answer: C.

Rationale: Administration of subcutaneous medications is included in LPN/LVN education and scope of practice. The other actions require more education and scope of practice and should be done by the registered nurse (RN).

  1. Answer: B.

Rationale: Developing a regular voiding schedule will prevent incontinence and may increase patient awareness of a full bladder. A 1200 mL fluid restriction may lead to dehydration. Intermittent catheterization and the use of a condom catheter are appropriate in the acute phase of stroke. Still, they should not be considered solutions for long-term management because of the risks for urinary tract infection (UTI) and skin breakdown.

  1. Answer: C.

Rationale: The information supports the diagnosis of a disabled family coping because the wife does not understand the rehabilitation program. No data support low self-esteem, and the patient is attempting independence. The data do not support an interruption in family processes because this may be a typical pattern for the couple. There is no indication that the patient has impaired nutrition.

  1. Answer: A.

Rationale: The patient with a subarachnoid hemorrhage usually has a minimal activity to prevent cerebral vasospasm or further bleeding and is at risk for venous thromboembolism (VTE). Activities such as coughing and sitting up that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided. Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.

  1. Answer: D.

Rationale: Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to the patient’s emotional state. Depression after a stroke is common, but the suddenness of the patient’s outburst suggests that depression is not the primary cause of the behavior. The family should stay with the patient. The crying is not within the patient’s control, and asking the patient to stop will lead to embarrassment.

  1. Answer: D.

Rationale: Nonmodifiable risk factors for stroke include age (older than 65 years), male gender, ethnicity, or race (incidence is highest in African Americans; next highest in Hispanics, Native Americans/Alaska Natives, and Asian Americans; and next highest in white people), and family history of stroke or personal history of a transient ischemic attack or stroke. Modifiable risk factors for stroke include hypertension (most important), heart disease (especially atrial fibrillation), smoking, excessive alcohol consumption (causes hypertension), abdominal obesity, sleep apnea, metabolic syndrome, lack of physical exercise, poor diet (high in saturated fat and low in fruits and vegetables), and drug abuse (especially cocaine). Other risk factors for stroke include a diagnosis of diabetes mellitus, increased serum levels of cholesterol, birth control pills (high levels of progestin and estrogen), history of migraine headaches, inflammatory conditions, hyperhomocysteinemia, and sickle cell disease.

  1. Answer: D.

Rationale: Transient ischemic attacks usually lasts shorter and has a higher probability of the patient returning to normal function after the attack. However, the nurse should note that the existence of TIAs also places the patient at higher risk of suffering from strokes, so health education must be given to the patient to help prevent it from happening.

  1. Answer: C.

Rationale: A carotid endarterectomy is the removal of an atherosclerotic plaque in the carotid arteries that may impair circulation enough to cause a stroke.

  1. Answer: C.

Rationale: The communication between cerebral arteries in the circle of Willis provides collateral circulation, which may maintain circulation to an area of the brain if its original blood supply is obstructed. All areas of the brain require a constant blood supply, and atherosclerotic plaques are not readily reversed. Neurologic deficits can result from ischemia caused by many factors.

  1. Answer: C.

Rationale: The brain area perfused by the affected artery- a clinical manifestation of altered neurologic function differ, depending primarily on the specific cerebral artery involved and the site of the brain that is perfused by the artery. The degree of impairment depends on the rapidity of onset, the size of the lesion, and the presence of collateral circulation.

  1. Answer: A.

Rationale: CT scan- A CT scan is the most commonly used diagnostic test to determine the lesion’s size and location and differentiate a thrombotic stroke from a hemorrhagic stroke. Positron emission tomography (PET) will show the metabolic activity of the brain and provide a depiction of the extent of tissue damage after a stroke. Lumbar punctures are not performed routinely because of the chance of increased intracranial pressure causing herniation. Cerebral arteriograms are invasive and may dislodge an embolism or cause further hemorrhage; they are performed only when no other test can provide the needed information.

  1. Answer: D.

Rationale: Maintenance of respiratory function with a patent airway and oxygen administration- the first priority in the acute management of the patient with a stroke is the preservation of life. Because the patient with a stroke may be unconscious or have a reduced gag reflex, it is most important to maintain a patent airway for the patient and provide oxygen if respiratory effort is impaired. IV fluid replacement, treatment with osmotic diuretics, and perhaps hypothermia may be used for further treatment.

  1. Answer: C.

Rationale: Scrambled eggs are the best option since soft foods that provide enough texture, flavor, and bulk to stimulate swallowing should be used for dysphasia patients. Thin liquids are difficult to swallow, and patients may not be able to control them in the mouth. Pureed foods are often too bland and too smooth, and milk products should be avoided because they tend to increase mucus viscosity and salivation.

  1. Answer: D.

Rationale: tPA dissolves clots and increases the risk of bleeding. It is not used with hemorrhagic strokes. If the patient had a thrombotic/embolic stroke, the time frame would be necessary and a history of surgery. The nurse should answer the question as accurately as possible and then encourage the individual to talk with the primary care physician if they have further questions.

  1. Answer: B.

Rationale: The average pressure of oxygen in brain tissue (PbtO2) is 20 to 40 mm Hg. The normal jugular venous oxygen saturation (SjvO2) is 55% to 75% and indicates total venous brain tissue extraction of oxygen; this is used for short-term monitoring. The MAP of 70 to 150 mm Hg is needed for effective autoregulation of CBF. The normal range for PaO2 is 80 to 100 mm Hg.

  1. Answer: C.

Rationale: A PaO2 of 70 mm Hg reflects hypoxemia that may lead to further decreased cerebral perfusion. PaO2 should be maintained at greater than or equal to 100 mm Hg. The pH and SaO2 are within the normal range, and a PaCO2 of 35 mm Hg reflects a normal value.

  1. Answer: B.

Rationale: If reflex posturing occurs during the range of motion (ROM) or patient positioning, these activities should be done less frequently until the patient’s condition stabilizes because posturing can cause increases in ICP and may indicate herniation. Neither restraints nor central nervous system (CNS) depressants would be indicated.

  1. Answer: D.

Rationale: Active range of motion (ROM) should be initiated on the unaffected side as soon as possible, and passive ROM of the affected side should be started on the first day. Having the patient actively exercise the unaffected side provides the patient with active and passive ROM as needed. The use of footboards is controversial because they stimulate plantar flexion. The unaffected arm should be supported, but immobilization may precipitate a painful shoulder-hand syndrome. The patient should be positioned with each joint higher than the joint proximal to it to prevent dependent edema.

  1. Answer: A.

Rationale: A helpless client should be positioned on the side, not on the back, with the head on a small pillow. A lateral position helps secretions escape from the throat and mouth, minimizing the risk of aspiration. It may be necessary to suction the client if he aspirates. Suction equipment should be nearby. It is safe to use a padded tongue blade, and the client should receive oral care, including brushing with a toothbrush.

  1. Answer: A.

Rationale: The primary reason for the nursing assessment of a client’s functional status before and after a stroke is to guide the plan. The assessment does not help predict how far the rehabilitation team can help the client recover from the residual effects of the stroke, only what strategies can help a client who has moved from one functional level to another. The nursing assessment of the client’s functional status is not a motivating factor.

  1. Answer: D.

Rationale: To expand the visual field, the partially sighted client should be taught to turn the head from side to side when walking. Neglecting to do so may result in accidents. This technique helps maximize the use of remaining sight. Covering an eye with a patch will limit the field of vision. Personal items can be placed within sight and reach, but most accidents occur from tripping over items that cannot be seen. It may help the client to see the door, but walking presents the primary safety hazard.

  1. Answer: C.

Rationale: A client with brain damage may be emotionally labile and may cry or laugh for no explanation. Crying is best dealt with by attempting to divert the client’s attention. Ignoring the behavior will not affect the mood swing or the crying and may increase the client’s sense of isolation. Telling the client to stop is inappropriate.

  1. Answer: D, E.

Rationale: When offering emotional support to a discouraged client who has a negative self-concept because of physical handicaps, the nurse should approach the client with encouragement and patience. The client should be praised when they show progress in efforts to overcome handicaps. An attitude of helpfulness and sympathy allows the client to assume the role of someone not ordinary, not like others. Regardless of the handicap, the client still feels the same inside and has the exact innate needs for their growth and developmental age group. An attitude of charity tends to make the client feel like a “charity case” or like someone who is given something free because of his “condition.” The client feels unequal to his peers or unable to fulfill the role relationships obtained before the stroke. An approach using firmness is inappropriate because it implies that the client can do better if he tries more complex and leaves no room for softness in overcoming a negative self-concept.

  1. Answer: C.

Rationale: Thrombolytic enzyme agents are used for clients with a thrombotic stroke to dissolve emboli, thus reestablishing cerebral perfusion. They do not increase vascular permeability, cause vasoconstriction, or prevent further hemorrhage.

  1. Answer: C.

Rationale: Pulling the client up under the arm can cause shoulder displacement. A belt around the waist should be used to move the client. Passive range of motion exercises prevent contractures and atrophy. Raising the foot of the bed assists in venous return to reduce edema. High-top tennis shoes are used to avoid foot drop.

  1. Answer: D.

Rationale: Helping the patient and family understand the significance of residual stroke damage to promote problem-solving and planning- the patient and family need accurate and complete information about the effects of the stroke to solve the problem and make plans for chronic care. It is uncommon for patients with significant strokes to return entirely to pre-stroke function, behaviors, and role, and both the patient and family will mourn these losses. The patient’s specific needs for care must be identified, and rehabilitation efforts should be continued at home. Family therapy and support groups may be helpful for some patients and families.

References

  1. Billings, D. (2019). Lippincott Q&A Review for NCLEX-RN. LWW.
  2. Brunner, L., Suddarth, D., & Squazzo, K. (2018). Study Guide for Brunner and Suddarth’s Textbook of Medical-Surgical Nursing. Wolters Kluwer.
  3. Cuellar, T. (2019). HESI comprehensive review for the NCLEX-RN examination (6th ed.).
  4. Irwin, B., & Burckhardt, J. (2018). NCLEX-RN Prep 2018. Kaplan Publishers.
  5. Lightsey, R., & Santopoalo, R. (2019). NCLEX-RN Practice Test Questions 2019 & 2020.
  6. Silvestri, L. (2019). Saunders Comprehensive Review for the NCLEX-RN EXAMINATION. Saunders.
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Nhiña Sandeep de Rosas, MAN, DIH, DSHRM, RN currently works for the Department of Health CHD Mimaropa as a Training Specialist. She is also a Nurse Licensure Exam and NCLEX-RN reviewer on her free time. She has her USRN licenses in New York and Vermont, having passed the NCLEX-RN in 2007.Since 2006, she has been a nurse educator and worked as a clinical instructor and classroom lecturer for Unciano Colleges (College of Nursing) in Antipolo City. She has earned her Master’s Degree in Nursing and Diploma in International Health at the University of the Philippines Open University; and her Diploma in Strategic Human Resource Management at the Ateneo de Manila University.

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