NCLEX STYLE QUESTIONS ON INTERVENTIONS

Question 1

A nurse is caring for a patient admitted with a cerebrovascular attack (CVA). To promote hip hyperextension, prevent contractures, and drain secretions, which position should the nurse utilize for short periods?

A. Side-lying with pillows between the legs.

B. Supine with the head of the bed elevated 30 degrees.

C. Prone positioning.

D. High Fowler's position.

Side-lying with pillows between the legs is for side-lying. The other options do not specifically address these goals.

Correct Answer: A

Question 2

When providing care for a patient with a flaccid shoulder following a stroke, which nursing intervention is crucial to prevent shoulder pain?

A. Encouraging the patient to use overhead pulleys for range of motion.

B. Lifting the patient by pulling on the affected arm.

C. Ensuring proper positioning and use of a sling.

D. Avoiding early out-of-bed activity.

To prevent shoulder pain, it is crucial to avoid lifting or pulling the flaccid shoulder and to avoid overhead pulleys. Proper positioning and sling use are recommended. Early out-of-bed activity is generally encouraged to improve mobility.

Correct Answer: C

Question 3

A patient with a CVA has visual field deficits. Which nursing intervention would best assist the patient in adjusting to these changes?

A. Minimizing all visual stimuli in the environment.

B. Placing visual stimuli only on the unaffected side.

C. Encouraging head turning to compensate and attention to the affected side.

D. Administering analgesics for eye pain.

For visual field deficits, nursing interventions include placing visual stimuli, encouraging head turning to compensate for contact, attention to the affected side, increased lighting, eyeglasses, and reminders of the affected side and extremity placement. Minimizing all visual stimuli or placing them only on one side would hinder adaptation. Analgesics are for pain, not specifically for visual field deficits.

Correct Answer: C

Question 4

A nurse is preparing to feed a patient who has had a stroke and is at risk for aspiration. Which intervention is most appropriate to ensure safe nutrition?

A. Providing a regular diet and encouraging large boluses of food.

B. Allowing the patient to remain supine during meals.

C. Assessing the swallowing reflex within 24 hours of admission and offering thick liquids/pureed diet.

D. Discontinuing all oral intake and relying solely on a GI feeding tube.

For patients at risk for aspiration, a swallow assessment should be performed within 24 hours. Alternative swallowing techniques, small boluses, easy-to-swallow foods, thick liquids/pureed diet, and an upright position with a chin tuck are recommended. A GI feeding tube is used if needed, but oral intake should be assessed first.

Correct Answer: C

Question 5

A patient with a right-sided paralysis due to a stroke is experiencing aphasia. Which communication strategy should the nurse prioritize?

A. Speaking in a loud voice to ensure the patient hears.

B. Using complex sentences and abstract topics.

C. Facing the patient, making eye contact, using short phrases, and concrete topics.

D. Minimizing all gestures to avoid confusion.

For aphasia, the nurse should face the patient, make eye contact, use a usual tone, short phrases, pauses, concrete topics, gestures, pictures, and writing, and minimize distractions. Aphasia is common with right-side paralysis. Speaking loudly, using complex sentences, or minimizing gestures are not appropriate strategies.

Correct Answer: C

Question 6

The nurse is caring for a patient post-stroke. To maintain skin integrity, which intervention is a priority?

A. Applying skin emollients only once a day.

B. Turning the patient every 4 hours.

C. Assessing skin frequently, especially over bony areas, and implementing a turning schedule every 2 hours.

D. Relying solely on a specialty bed for pressure relief.

To maintain skin integrity, nurses should assess skin frequently, especially over bony areas, and implement a turning schedule every 2 hours. Specialty beds are used in the acute phase, but a turning schedule is still essential.

Correct Answer: C

Question 7

A patient is admitted to the emergency department with suspected ischemic stroke. Which medication is considered the "gold standard" for thrombolytic therapy in ischemic stroke/TIA management?

A. Warfarin.

B. Aspirin.

C. Alteplase (rTPA).

D. Atorvastatin.

Thrombolytic therapy with rTPA is considered the "gold standard" for ischemic stroke/TIA management. Warfarin is an anticoagulant, aspirin is a platelet inhibitor, and atorvastatin is a statin.

Correct Answer: C

Question 8

For a patient receiving rTPA for an ischemic stroke, the nurse understands that administration should ideally occur within how many hours of symptom onset?

A. 6 hours.

B. 12 hours.

C. 3 hours.

D. 24 hours.

Thrombolytic therapy (rTPA) timing states it should be administered within 3 hours of symptom onset or 60 minutes of ED arrival. It is contraindicated beyond 6 hours.

Correct Answer: C

Question 9

A nurse is monitoring a patient post-rTPA administration. Which intervention is a critical patient care consideration?

A. Administering anticoagulants immediately after rTPA.

B. Delaying insertion of a nasogastric tube (NGT) for 24 hours if possible.

C. Encouraging immediate ambulation.

D. Monitoring blood pressure every 4 hours.

After rTPA administration, anticoagulants should not be given for 24 hours. NGT, urinary catheters, and arterial lines should be delayed for 24 hours if possible. Blood pressure should be maintained at less than 180/110 mmHg, implying more frequent monitoring than every 4 hours.

Correct Answer: B

Question 10

A patient is undergoing evaluation for a transient ischemic attack (TIA) and has significant carotid stenosis. Which surgical management option might be considered?

A. Craniotomy.

B. Ventricular Catheter Drainage.

C. Carotid Endarterectomy.

D. Aneurysm Clipping.

Carotid endarterectomy is indicated for TIA/mild stroke with significant carotid stenosis. The other options are surgical management for hemorrhagic strokes.

Correct Answer: C

Question 11

In the management of hemorrhagic stroke, which intervention is primarily aimed at preventing agitation and increased intracranial pressure (ICP)?

A. IV Hydration.

B. DVT Prophylaxis with sequential compression devices.

C. Bed Rest and Sedation.

D. Hemoglobin/Hematocrit Monitoring.

Bed rest and sedation are used in hemorrhagic stroke management to prevent agitation and increased ICP. The other options have different purposes: IV hydration improves cerebral blood flow and reduces blood viscosity; DVT prophylaxis prevents deep vein thrombosis; and hemoglobin/hematocrit monitoring maintains tissue oxygenation.

Correct Answer: C

Question 12

A nurse is caring for a patient with a hemorrhagic stroke and is monitoring for vasospasm. Which diagnostic tool is commonly used for vasospasm monitoring?

A. Electrocardiogram (ECG).

B. Doppler or angiography.

C. Chest X-ray.

D. Lumbar puncture.

Doppler or angiography is used for vasospasm monitoring in hemorrhagic stroke management. The other options are not primarily used for vasospasm monitoring.

Correct Answer: B

Question 13

For a patient with a hemorrhagic stroke experiencing increased ICP, which pharmacological intervention is used to reduce ICP, and what is a key nursing consideration?

A. Acetaminophen; monitor for fever.

B. Mannitol; monitor for dehydration and electrolyte imbalances.

C. Labetalol; monitor blood pressure.

D. Phenytoin; monitor for seizure activity.

Mannitol is used to reduce ICP in hemorrhagic stroke, and the nurse should monitor for dehydration and electrolyte imbalances. Acetaminophen is for fever management. Labetalol is an antihypertensive. Phenytoin is an anticonvulsant for seizure prevention.

Correct Answer: B

Question 14

A patient with a hemorrhagic stroke has a history of Warfarin use. Which agents would the nurse anticipate administering to reverse the effects of Warfarin?

A. Atorvastatin and Amlodipine.

B. Fresh frozen plasma (FFP) and Vitamin K.

C. Nimodipine and Phenytoin.

D. Rivaroxaban and Dabigatran.

For Warfarin reversal in hemorrhagic stroke, fresh frozen plasma (FFP) and Vitamin K are administered. The other options are not used for Warfarin reversal: Atorvastatin is a statin, Amlodipine is an antihypertensive. Nimodipine prevents vasospasm, and Phenytoin prevents seizures. Rivaroxaban and Dabigatran are anticoagulants.

Correct Answer: B

Question 15

Which surgical procedure for hemorrhagic stroke involves the removal of part of the skull to assess cerebral swelling and evacuate a hematoma?

A. Aneurysm Clipping.

B. Ventricular Catheter Drainage.

C. Burr Holes.

D. Decompressive Craniectomy.

Burr holes are performed to assess cerebral swelling and hematoma evacuation. Aneurysm clipping prevents rebleeding and removes clots. Ventricular catheter drainage is for CSF drainage. Decompressive craniectomy is skull removal for severe swelling.

Correct Answer: C

Question 16

A nurse is planning an exercise program for a patient recovering from a CVA. Which principle should guide the nurse's approach?

A. Long, infrequent exercise sessions to maximize endurance.

B. Encouraging exercise only on the affected side to promote recovery.

C. Short, frequent exercise sessions, monitoring for pulmonary embolus/cardiac workload.

D. Discouraging early out-of-bed activity.

Establishing an exercise program involves short, frequent exercise sessions, monitoring for pulmonary embolus/cardiac workload, encouraging unaffected side exercise, using a written schedule with supervision, and early out-of-bed activity.

Correct Answer: C

Question 17

When assisting a male patient with bladder control after a stroke, which intervention is specifically recommended?

A. Limiting fluid intake to reduce voiding frequency.

B. Avoiding a voiding schedule.

C. Encouraging an upright or standing position for voiding.

D. Relying solely on indwelling catheterization.

For attaining bowel and bladder control, interventions include intermittent catheterization, a voiding schedule, and an upright/standing position for males. Limiting fluids excessively, avoiding a voiding schedule, or relying solely on anindwelling catheter are not recommended.

Correct Answer: C

Question 18

A patient post-stroke is experiencing cognitive-perceptual deficits. Which nursing intervention would be most beneficial for improving thought processes?

A. Providing negative feedback to motivate improvement.

B. Focusing only on areas of weakness.

C. Implementing cognitive-perceptual retraining, visual imagery, and reality orientation.

D. Avoiding neuropsychological testing.

Improving thought processes involves cognitive-perceptual retraining, visual imagery, reality orientation, cueing, reviewing neuropsychological testing, observing performance/progress, positive feedback, building confidence, and capitalizing on strengths.

Correct Answer: C

Question 19

The nurse is providing education to the family of a patient who has had a stroke. Which statement reflects an appropriate expectation regarding long-term rehabilitation?

A. "The patient will likely make a full and rapid recovery."

B. "Long-term rehabilitation will focus on encouraging complete patient dependence."

C. "Long-term rehabilitation will require a supportive, optimistic attitude and encourage patient independence."

D. "Sexual dysfunction is not an expected issue after a stroke."

For improving family coping, education should cover expected outcomes, encouraging patient independence, and long-term rehabilitation expectations with a supportive, optimistic attitude. Sexual dysfunction can be an issue, and interventions should be discussed.

Correct Answer: C

Question 20

During a neurological assessment of a patient with an ischemic stroke, the nurse would commonly use which assessment tools?

A. Braden Scale and Mini-Mental State Examination (MMSE).

B. Glasgow Coma Scale (GCS) and National Institutes of Health Stroke Scale (NIHSS).

C. Morse Fall Scale and Pain Assessment Tool.

D. Functional Independence Measure (FIM) and Barthel Index.

Frequent neurological assessments for ischemic stroke include the Glasgow Coma Scale (GCS), National Institutes of Health Stroke Scale (NIHSS), and cranial nerve assessments. The other options are for different assessment purposes (e.g., skin integrity, cognitive function, fall risk, pain, functional independence).

Correct Answer: B

Question 21

A nurse is providing education to a patient taking Aspirin and Clopidogrel after an ischemic stroke. What instruction is essential for the nurse to provide regarding the administration of Aspirin?

A. "Take Aspirin on an empty stomach to improve absorption."

B. "Take Aspirin with food and consider proton pump inhibitors (PPIs) to protect your gastric lining."

C. "Crush the Aspirin before administration for faster effect."

D. "Discontinue Clopidogrel if any bruising occurs."

When administering aspirin, it should be given with food, and proton pump inhibitors (PPIs) may be used to protect the gastric lining. Taking it on an empty stomach increases gastric irritation. Crushing medication depends on the specific formulation and is not a universal rule. Discontinuing medication due to bruising should only be done under medical guidance.

Correct Answer: B

Question 22

A patient with a history of atrial fibrillation experiences an ischemic stroke. Which class of medications is specifically indicated for this patient to prevent future strokes caused by cardiac arrhythmias?

A. Platelet Inhibitors

B. Statins

C. Anticoagulants

D. Antihypertensive Medications

Anticoagulants, such as Warfarin, Dabigatran, and Rivaroxaban, are prescribed for strokes caused by atrial fibrillation or other cardiac arrhythmias. Platelet inhibitors like Aspirin prevent clot formation but are not the primary treatment for embolic strokes from cardiac sources. Statins reduce atherosclerotic plaque formation. Antihypertensive medications manage blood pressure.

Correct Answer: C

Question 23

When administering rTPA, what is the correct dosage and administration schedule?

A. 0.5 mg/kg total dose, given as a bolus over 5 minutes.

B. 0.9 mg/kg total dose (maximum 90 mg), with 10% given as an IV bolus over 1 minute and the remaining 90% infused over 1 hour.

C. 1.0 mg/kg total dose, infused over 30 minutes.

D. 0.9 mg/kg total dose, given as a continuous infusion over 24 hours.

The correct dosage for rTPA is 0.9 mg/kg (maximum 90 mg), administered as a 10% IV bolus over 1 minute, with the remaining 90% infused over 1 hour.

Correct Answer: B

Question 24

A patient has just undergone a carotid endarterectomy. Which nursing intervention is a priority in the immediate postoperative period?

A. Encouraging deep breathing and coughing every hour.

B. Monitoring neurological and vascular status.

C. Applying warm compresses to the surgical site.

D. Restricting oral intake for 24 hours.

Post-carotid endarterectomy, priority nursing interventions include neurological and vascular status monitoring, hemodynamic and cardiac status monitoring, cranial nerve assessment (VII, X, XI, XII), and hematoma formation monitoring. While deep breathing and coughing are general postoperative interventions, neurological and vascular monitoring are specific and critical for this procedure.

Correct Answer: B

Question 25

A patient with a hemorrhagic stroke is receiving DVT prophylaxis. Which measures are commonly used for this purpose?

A. Anticoagulants like Warfarin.

B. Sequential compression devices or anti-embolic stockings.

C. High-dose Aspirin therapy.

D. Early and aggressive ambulation.

For DVT prophylaxis in hemorrhagic stroke, sequential compression devices or anti-embolic stockings are used. Anticoagulants are generally avoided or used with extreme caution due to the risk of exacerbating the hemorrhage. Early and aggressive ambulation may not be feasible or safe in the acute phase of a hemorrhagic stroke.

Correct Answer: B

Question 26

Triple H Therapy (Hypervolemia, Hypertension, Hemodilution) is a management strategy for which specific complication in hemorrhagic stroke?

A. Seizure prevention.

B. Vasospasm prevention.

C. ICP reduction.

D. Bowel and bladder control.

Triple H Therapy (Hypervolemia, Hypertension, Hemodilution) is utilized for vasospasm prevention in hemorrhagic stroke management.

Correct Answer: B

Question 27

A nurse is assisting a patient with adjusting to physical changes after a stroke, specifically addressing visual field deficits. Which intervention should the nurse include in the plan of care?

A. Discouraging turning the head to compensate for vision loss.

B. Placing all personal items and the call light on the patient's affected side.

C. Reminding the patient about the affected side and extremity placement.

D. Keeping the room dimly lit to avoid overstimulation.

For visual field deficits, the nurse should encourage head turning to compensate for contact, provide attention to the affected side, increase lighting, ensure eyeglasses are worn, and offer reminders of the affected side and extremity placement. Placing all items on the affected side without prompting compensation can frustrate the patient, and a dimly lit room would hinder vision.

Correct Answer: C

Question 28

When planning care to improve mobility and prevent joint deformities in a patient with a cerebrovascular attack, the nurse should ensure passive range of motion (ROM) exercises are performed how often?

A. Once a day.

B. Every 2 hours.

C. 4-5 times/day.

D. Only when the patient expresses willingness.

Passive ROM exercises should be performed 4-5 times/day to improve mobility and prevent joint deformities. Positioning every 2 hours is for skin integrity and pressure relief.

Correct Answer: C

Question 29

A patient post-stroke is experiencing dysphagia. Before administering oral medications, what is the priority assessment for the nurse?

A. Pain level.

B. Swallowing reflex.

C. Blood pressure.

D. Level of consciousness.

Assessment of the swallowing reflex before oral administration is crucial due to the risk of dysphagia. While other assessments are important, the swallowing reflex directly impacts the safe administration of oral medications.

Correct Answer: B

Question 30

A patient with a hemorrhagic stroke requires pain management for head and neck pain. Which medication type is appropriate for this?

A. Anticoagulants.

B. Analgesics.

C. Thrombolytics.

D. Statins.

Analgesics are appropriate for managing head and neck pain in patients with hemorrhagic stroke. Anticoagulants and thrombolytics are contraindicated or used with extreme caution. Statins are for cholesterol management.

Correct Answer: B

Question 31

A nurse is monitoring a patient for potential complications after a hemorrhagic stroke. An increase in ICP is a concern. Which strategies are used to reduce ICP?

A. Head elevation, hyperventilation, and hypertonic saline.

B. Maintaining a flat bed position and avoiding hyperventilation.

C. Increasing fluid intake and administering hypotonic solutions.

D. Encouraging Valsalva maneuvers.

Strategies for ICP reduction include head elevation, hyperventilation, and hypertonic saline. Maintaining a flat bed position, increasing fluid intake, or encouraging Valsalva maneuvers would increase ICP.

Correct Answer: A

Question 32

Which cranial surgical approach is used to access the pituitary region via the nasal cavity?

A. Supratentorial

B. Infratentorial

C. Transsphenoidal

D. Craniotomy

The transsphenoidal approach is specifically located for pituitary region access via the nasal cavity. Supratentorial is above the tentorium, and infratentorial is below the tentorium/brain stem. Craniotomy is a general term for opening the skull.

Correct Answer: C

Question 33

A nurse is reviewing a patient's orders for acute ischemic stroke management. The order includes oxygen therapy. The nurse understands that supplemental oxygen is administered if the patient's SpO2 falls below what percentage?

A. 98%

B. 94%

C. 90%

D. 88%

Supplemental oxygen is administered if the patient's SpO2 is less than 94%.

Correct Answer: B

Question 34

In the acute phase of an ischemic stroke, the nurse recognizes that continuous hemodynamic monitoring involves assessing which parameters?

A. Temperature and respiratory rate.

B. Blood pressure, hemoglobin, and hematocrit levels.

C. Blood glucose and electrolyte levels.

D. Oxygen saturation and end-tidal CO2.

Hemodynamic monitoring in ischemic stroke includes continuous monitoring of blood pressure, hemoglobin, and hematocrit levels.

Correct Answer: B

Question 35

When managing a patient with a cerebrovascular attack, the nurse implements positioning strategies to prevent complications. To prevent venous stasis and promote new CNS pathways, which action is important?

A. Keeping the patient in a supine position at all times.

B. Avoiding any movement of the affected limbs.

C. Regularly changing the patient's position, ensuring proper body alignment.

D. Limiting activities that stimulate new CNS pathways.

Proper positioning every 2 hours prevents venous stasis and promotes new CNS pathways. Keeping the patient supine, avoiding movement, or limiting activities would be detrimental.

Correct Answer: C

Question 36

A nurse is educating a patient about risk factors for ischemic stroke. Which of the following is a modifiable risk factor that should be emphasized in the teaching?

A. Age.

B. Family history of stroke.

C. Hypertension.

D. Gender.

Hypertension is a modifiable risk factor for stroke. Age, family history, and gender are non-modifiable risk factors.

Correct Answer: C

Question 37

A patient who suffered a stroke is experiencing impaired sensation on one side of their body. When changing the patient's position, what should the nurse keep in mind regarding the affected side?

A. It is permissible to limit time on the affected side if sensation is impaired.

B. The patient should always lie on the affected side to promote circulation.

C. Only position the patient on the unaffected side.

D. Frequent deep tissue massage on the affected side is necessary.

When changing positions, it is important to limit time on the affected side if sensation is impaired to prevent pressure injuries.

Correct Answer: A

Question 38

When establishing an exercise program for a patient recovering from a stroke, what should the nurse include regarding assistive devices for ambulation?

A. Assistive devices should be avoided to encourage natural gait.

B. Only parallel bars should be used for initial ambulation.

C. Assistive devices like a tilt table, wheelchair, parallel bars, or cane can be used as needed.

D. Ambulation should only begin once full strength is regained.

Assistive devices such as a tilt table, wheelchair, parallel bars, and cane can be used to aid in preparing for ambulation. Ambulation begins early and progressively.

Correct Answer: C

Question 39

A patient recovering from a stroke is experiencing difficulty with communication due to aphasia. Which nursing intervention is most effective in facilitating communication?

A. Using complex medical terminology to encourage cognitive stimulation.

B. Shouting to ensure the patient hears all words.

C. Using consistent words and gestures.

D. Discussing abstract topics to challenge the patient.

For improving communication in aphasia, the nurse should use consistent words and gestures, short phrases, and concrete topics. Shouting or using complex/abstract topics would hinder communication.

Correct Answer: C

Question 40

In the acute management of ischemic stroke, which vital sign is crucial to monitor continuously, and what is a primary goal for its management?

A. Temperature; goal to maintain hypothermia.

B. Heart rate; goal to keep it below 60 bpm.

C. Blood pressure; goal to maintain it within a specific therapeutic range.

D. Respiratory rate; goal to keep it above 30 breaths/min.

Continuous monitoring of blood pressure is critical in ischemic stroke management, with the goal of maintaining it within a specific therapeutic range (e.g., less than 180/110 mmHg post-rTPA). Other vital signs have different management goals.

Correct Answer: C

Question 41

A nurse is developing a plan of care for a patient recovering from a stroke, addressing potential sexual dysfunction. Which intervention should the nurse include?

A. Avoiding discussion of sexual concerns as it may cause discomfort.

B. Advising the patient that sexual activity is contraindicated after a stroke.

C. Assessing the patient's sexual history and providing interventions such as alternative positions or counseling.

D. Directing the patient to abstain from sexual activity for at least one year.

For helping the patient cope with sexual dysfunction, the nurse should assess sexual history and provide interventions that may include alternative positions, counseling, or referrals. Avoiding discussion or advising complete abstinence is not appropriate.

Correct Answer: C

Question 42

A patient in the emergency department is suspected of having an acute ischemic stroke and is exhibiting signs of respiratory distress. What is the priority nursing intervention for airway management in this situation?

A. Administering supplemental oxygen via nasal cannula.

B. Placing the patient in a prone position.

C. Performing endotracheal intubation.

D. Initiating non-rebreather mask oxygen delivery.

If a patient with suspected ischemic stroke is in respiratory distress, endotracheal intubation is the priority for airway management. Supplemental oxygen alone might not be sufficient if distress is severe.

Correct Answer: C

Question 43

A patient with a hemorrhagic stroke is prescribed Nimodipine. The nurse understands that this medication is primarily used to prevent which complication?

A. Seizures.

B. Increased intracranial pressure (ICP).

C. Vasospasm.

D. Deep vein thrombosis (DVT).

Nimodipine is a calcium channel blocker used specifically to prevent vasospasm in patients with hemorrhagic stroke, particularly subarachnoid hemorrhage.

Correct Answer: C

Question 88

A nurse is explaining cerebral blood flow to a group of students. The nurse highlights that cerebral blood vessels are unique compared to other body organs in that they primarily have how many layers?

A. 1 layer.

B. 2 layers.

C. 3 layers.

D. 4 layers.

Unlike other blood vessels, cerebral blood vessels typically have only two layers, making them more prone to rupture.

Correct Answer: B

Question 89

Which statement accurately describes a characteristic of cerebral venous circulation?

A. It contains valves to prevent backflow of blood.

B. It carries oxygenated blood back to the heart.

C. It relies heavily on gravity and blood pressure for backflow due to the absence of valves.

D. It starts at the internal jugular veins and ends at the cerebral veins.

Cerebral venous circulation has no valves to prevent backflow, so backflow relies heavily on gravity and blood pressure. It carries deoxygenated blood from the brain.

Correct Answer: C

Question 90

A patient is admitted with a severe headache, described as "the worst headache of my life." The nurse suspects a ruptured intracranial aneurysm. Which site is a frequent location for the formation and rupture of cerebral aneurysms?

A. Mid-sagittal sinus.

B. Bifurcations of large arteries in the Circle of Willis.

C. External carotid artery branches.

D. Vertebral arteries near their origin from the subclavian arteries.

Aneurysms, which are weak spots in arterial walls, are frequently formed and rupture at bifurcations of large arteries in the Circle of Willis.

Correct Answer: B

Question 91

A nurse is reviewing the significance of the "penumbra area" in an ischemic stroke. The nurse understands that this area is important because it represents:

A. The core infarct where irreversible damage has already occurred.

B. A zone of ischemic but potentially salvageable brain tissue.

C. The region of the brain with normal blood flow.

D. An area of brain tissue that stores excess oxygen and glucose.

The penumbra is the region of brain tissue surrounding the core infarct that experiences reduced blood flow but is not yet completely infarcted; it is a zone of ischemic but potentially salvageable tissue.

Correct Answer: B

Question 92

In the context of stroke management, the phrase "Time is Brain" primarily refers to the rapid loss of what during ischemia, necessitating urgent treatment?

A. Blood pressure.

B. Neurons.

C. CSF volume.

D. Cerebral blood vessel elasticity.

"Time is Brain" signifies that during ischemia, neurons are rapidly lost, and untreated ischemic brain tissue ages significantly per hour, emphasizing the need for rapid treatment.

Correct Answer: B

Question 93

A nurse is comparing Intracerebral Hemorrhage (ICH) and Subarachnoid Hemorrhage (SAH). Which statement accurately distinguishes ICH?

A. Bleeding occurs into the subarachnoid space.

B. It is characterized by bleeding directly into the brain tissue.

C. It is typically caused by head trauma only.

D. It commonly results in brain stem herniation due to bleeding into the subarachnoid space.

Intracerebral Hemorrhage (ICH) is defined as bleeding directly into the brain tissue. Bleeding into the subarachnoid space is SAH.

Correct Answer: B

Question 94

A patient with a hemorrhagic stroke experiences a sudden worsening headache, confusion, and new onset of aphasia on day 8 post-stroke. The nurse suspects vasospasm. This complication is often linked to:

A. Rapid reabsorption of CSF.

B. Clot dissolution increasing vascular resistance.

C. Administration of anticoagulants.

D. Decreased cerebral blood volume.

Vasospasm pathophysiology indicates that clot dissolution (typically 7-10 days post-stroke) increases vascular resistance and leads to disrupted cerebral blood flow, causing new neurological deficits.

Correct Answer: B

Question 95

The nurse is observing a patient with suspected increased intracranial pressure (ICP) and notes the development of Cushing's Triad. Which set of vital signs constitutes Cushing's Triad?

A. Hypotension, tachycardia, and bradypnea.

B. Hypertension, bradycardia, and bradypnea.

C. Hypotension, bradycardia, and tachypnea.

D. Hypertension, tachycardia, and tachypnea.

Cushing's Triad, a late sign of increased ICP, consists of hypertension, bradycardia, and bradypnea.

Correct Answer: B

Question 96

A nurse is caring for a patient with increased ICP. The nurse understands that increased CO2 levels in the blood affect cerebral blood flow and ICP in what way?

A. Increased CO2 causes vasoconstriction, decreasing blood flow and ICP.

B. Increased CO2 causes vasodilation, increasing blood flow and ICP.

C. Decreased CO2 causes vasodilation, increasing blood flow and ICP.

D. CO2 levels have no direct impact on cerebral blood flow or ICP.

Increased CO2 levels cause vasodilation, which increases cerebral blood flow and consequently increases ICP.

Correct Answer: B

Question 97

A patient with a traumatic spinal cord injury develops myelomalacia. The nurse anticipates which primary treatment goal for this condition?

A. Administering broad-spectrum antibiotics to treat infection.

B. Clearing blockage or compression and stabilizing the injury area.

C. Initiating long-term anticoagulant therapy.

D. Performing immediate spinal fusion in all cases.

The goals of treatment for myelomalacia are to clear blockage or compression and stabilize the injury area. Management can be nonsurgical (bracing, PT, NSAIDs, gabapentinoids) or surgical (spinal decompression).

Correct Answer: B

Question 98

A patient is diagnosed with hematomyelia following a minor head injury. Which diagnostic test is considered the primary imaging modality for confirming this condition?

A. X-ray of the spine.

B. Spinal CT scan.

C. MRI of the spine with and without gadolinium.

D. Electromyography (EMG).

Hematomyelia, an intramedullary hemorrhage in the spinal cord, is primarily diagnosed through MRI (with and without gadolinium) and spinal CT scan. MRI is often preferred for soft tissue visualization.

Correct Answer: C