NCLEX STYLE LONG EXAM REVIEWER

A client arrives at the emergency department reporting sudden onset of right-sided weakness, slurred speech, and blurred vision that resolved completely within 30 minutes. The nurse suspects a Transient Ischemic Attack (TIA). Which statement accurately describes the most critical difference between a TIA and a Cerebrovascular Accident (CVA)?

A. TIA symptoms are typically caused by venous thrombi, while CVA symptoms are always arterial.

B. TIA symptoms resolve within 24 hours, whereas CVA symptoms cause permanent neurological deficits.

C. TIAs involve only the cerebral cortex, while CVAs can affect any brain region.

D. TIAs are typically hemorrhagic events, whereas CVAs are primarily ischemic.

Correct Answer: B TIA symptoms are transient and, by definition, resolve within 24 hours, leaving no permanent neurological deficit. CVA (stroke) symptoms result from brain cell death and cause lasting neurological impairment.

Incorrect Options:

A: Both TIAs and CVAs are predominantly arterial in origin, though rare venous causes exist for CVA.

C: TIAs can affect various brain regions, not just the cerebral cortex, depending on the blood vessel involved.

D: TIAs are almost exclusively ischemic, similar to the majority of CVAs. Hemorrhagic TIAs do not occur.

A nurse is educating a client who recently experienced a TIA. Which modifiable risk factor should the nurse emphasize as crucial to control to prevent a future CVA?

A. Age

B. Family history of stroke

C. Uncontrolled hypertension

D. Prior history of migraine headaches

Correct Answer: C Uncontrolled hypertension is a major modifiable risk factor for both TIA and CVA, significantly increasing the risk of both ischemic and hemorrhagic strokes.

Incorrect Options:

A: Age is a non-modifiable risk factor.

B: Family history is a non-modifiable risk factor.

D: While some studies suggest a link between migraines and stroke risk, it is not as strong or directly modifiable as hypertension.

The nurse is assessing a client presenting with symptoms suggestive of a TIA. Which diagnostic study is most critical to perform immediately to differentiate a TIA from an acute ischemic CVA?

A. Electroencephalogram (EEG)

B. Lumbar puncture

C. Computed Tomography (CT) scan of the brain

D. Carotid Doppler ultrasound

Correct Answer: C An urgent CT scan of the brain is crucial to rule out a hemorrhagic stroke, which has different acute management from an ischemic event. While a TIA doesn't show infarction on CT, it helps exclude other causes and guides immediate treatment decisions.

Incorrect Options:

A: EEG is used to detect seizure activity, not to differentiate TIA from CVA.

B: Lumbar puncture is used to diagnose infections or subarachnoid hemorrhage but is not the initial imaging choice for TIA/CVA differentiation.

D: Carotid Doppler ultrasound assesses carotid artery stenosis, which is a risk factor, but it doesn't immediately differentiate TIA from acute CVA.

A client with a history of TIAs is prescribed clopidogrel (Plavix). The nurse should instruct the client to immediately report which adverse effect?

A. Constipation

B. Nausea and vomiting

C. Easy bruising or unusual bleeding

D. Dizziness and lightheadedness

Correct Answer: C Clopidogrel is an antiplatelet medication. Easy bruising, petechiae, melena, or unusual bleeding are signs of increased bleeding risk and should be reported immediately as they could indicate a serious adverse effect.

Incorrect Options:

A: Constipation is not a common or critical adverse effect of clopidogrel.

B: Nausea and vomiting can occur but are generally less critical than bleeding unless severe.

D: Dizziness and lightheadedness can be general symptoms but are not specific to critical adverse effects of clopidogrel unless related to significant bleeding or hypotension.

A nurse is providing discharge teaching to a client diagnosed with a TIA. Which instruction is most important for the nurse to emphasize regarding future events?

A. "Avoid all strenuous physical activity to prevent another TIA."

B. "Any new, sudden neurological symptom, even if mild, requires immediate medical attention."

C. "Limit your fluid intake to prevent fluid overload, which can worsen TIA symptoms."

D. "Take over-the-counter pain relievers for any headache or vision changes."

Correct Answer: B A TIA is a warning sign of an impending stroke. Clients must understand the importance of seeking immediate medical attention for any new or recurrent neurological symptoms (e.g., FAST symptoms: Face drooping, Arm weakness, Speech difficulty, Time to call 911), as this could indicate a full-blown CVA.

Incorrect Options:

A: Strenuous activity generally doesn't directly cause TIAs, and regular, moderate exercise is often encouraged.

C: There is no general recommendation to limit fluid intake for TIA prevention; adequate hydration is important.

D: Clients should not self-medicate for new neurological symptoms. Headaches or vision changes could be symptoms of a TIA or CVA and require medical evaluation.

A client is admitted to the emergency department with sudden onset of right-sided hemiplegia, aphasia, and right facial droop. Based on these findings, the nurse suspects which type of CVA?

A. Right hemispheric ischemic stroke

B. Left hemispheric ischemic stroke

C. Cerebellar hemorrhagic stroke

D. Brainstem ischemic stroke

Correct Answer: B The left cerebral hemisphere controls language (aphasia) and sensation/movement on the right side of the body (right-sided hemiplegia and facial droop). Therefore, these symptoms point to a left hemispheric stroke.

Incorrect Options:

A: A right hemispheric stroke would typically cause left-sided deficits and neglect, often without primary aphasia.

C: A cerebellar stroke primarily affects coordination, balance, and fine motor skills.

D: Brainstem strokes cause a wide range of severe symptoms affecting cranial nerves, breathing, and consciousness, often with bilateral deficits.

A client experiencing an acute ischemic stroke is a candidate for tissue plasminogen activator (tPA). The nurse understands that a critical contraindication for tPA administration is:

A. Blood pressure 160/90 mmHg

B. Onset of stroke symptoms 2 hours ago

C. History of diabetes mellitus

D. Recent gastrointestinal bleed within the last 3 months

Correct Answer: D A recent gastrointestinal bleed (or any significant active bleeding or recent major surgery) is a major contraindication for tPA due to the increased risk of severe hemorrhage.

Incorrect Options:

A: While blood pressure needs to be controlled (typically <185/110 mmHg) before tPA, 160/90 mmHg is often within or can be safely lowered to the acceptable range.

B: Onset of symptoms within 2 hours is within the therapeutic window (typically 3-4.5 hours for eligible patients) for tPA, making it an indication, not a contraindication.

C: Diabetes mellitus is a risk factor for stroke but not a contraindication for tPA.

The nurse is caring for a client with dysphagia following a stroke. Which nursing intervention is most important to prevent aspiration?

A. Providing a straw for easier drinking.

B. Elevating the head of the bed to 30 degrees during meals.

C. Offering thin liquids to promote hydration.

D. Encouraging the client to tuck their chin when swallowing.

Correct Answer: D Tucking the chin (chin tuck) helps to close off the airway and facilitate passage of food or liquid into the esophagus, significantly reducing the risk of aspiration.

Incorrect Options:

A: Straws can increase the rate of liquid flow, making aspiration more likely in dysphagic clients.

B: While elevating the head of the bed is important, 30 degrees may not be sufficient for safe swallowing; 90 degrees (upright) or as high as tolerated is preferred during meals.

C: Thin liquids are the most difficult to control and are often restricted in clients with dysphagia; thickened liquids are usually preferred.

A client with a right hemispheric stroke demonstrates left-sided neglect. Which nursing intervention is appropriate to address this deficit?

A. Placing the client's call light on the left side of the bed.

B. Approaching the client from the left side to encourage left-sided engagement.

C. Reminding the client to look at their left side when eating or dressing.

D. Performing all personal care activities on the client's right side.

Correct Answer: C Clients with left-sided neglect need frequent reminders and cues to attend to the neglected side. Encouraging them to actively look at their left side helps improve awareness.

Incorrect Options:

A: The call light should be placed on the unaffected (right) side initially, or within reach, until the client's ability to attend to the left side improves. Placing it on the neglected side makes it inaccessible.

B: The nurse should approach from the unaffected (right) side initially to ensure the client acknowledges their presence and then reorient them to the neglected side.

D: Performing all care on the right side reinforces the neglect. Care should be provided from both sides, with emphasis on encouraging attention to the neglected side.

The spouse of a client recovering from a stroke asks the nurse about the long-term prognosis. The nurse explains that the most significant recovery from neurological deficits typically occurs during which timeframe post-stroke?

A. Within the first 24-48 hours

B. Within the first 3 to 6 months

C. Between 6 months and 1 year

D. After 1 year, with consistent therapy

Correct Answer: B The majority of neurological recovery and functional improvement after a stroke occurs within the first 3 to 6 months, although some continued improvement can be seen for up to a year or more.

Incorrect Options:

A: The first 24-48 hours are primarily for acute stabilization, not significant functional recovery.

C & D: While some improvement can occur in these later stages, the most rapid and substantial gains are usually observed in the initial 3-6 months.

A nurse is reviewing the medical record of a client diagnosed with myelomalacia. The nurse understands that this condition primarily refers to:

A. Softening of the brain tissue due to inflammation.

B. Degeneration and softening of the spinal cord.

C. Hardening of the spinal cord due to calcification.

D. A congenital malformation of the spinal column.

Correct Answer: B Myelomalacia literally means "softening of the spinal cord," typically due to ischemia (lack of blood supply), hemorrhage, or inflammation leading to tissue necrosis and degeneration.

Incorrect Options:

A: Softening of brain tissue is encephalomalacia.

C: Hardening would be sclerosis.

D: This describes conditions like spina bifida, which is different from myelomalacia.

Which of the following is a common cause of myelomalacia?

A. Prolonged exposure to sunlight

B. Acute spinal cord injury with severe contusion or ischemia

C. Chronic vitamin D deficiency

D. Systemic lupus erythematosus

Correct Answer: B Myelomalacia often results from severe acute spinal cord injury, particularly those involving significant contusion, compression, or disruption of blood supply leading to ischemia and necrosis of the spinal cord tissue.

Incorrect Options:

A: Sunlight exposure is not a cause of myelomalacia.

C: Vitamin D deficiency is related to bone health, not directly to spinal cord softening.

D: While systemic lupus erythematosus can affect the nervous system, it's not a primary or common cause of acute myelomalacia in the same way trauma or ischemia is.

A client with severe myelomalacia due to a traumatic spinal cord injury is exhibiting flaccid paralysis below the level of the lesion. The nurse anticipates the primary focus of long-term nursing care for this client will be:

A. Aggressive physical therapy to restore motor function.

B. Management of autonomic dysreflexia and spasticity.

C. Prevention of secondary complications such as pressure injuries and respiratory compromise.

D. Administration of corticosteroids to reverse the spinal cord softening.

Correct Answer: C Myelomalacia, especially when severe, indicates irreversible damage and tissue necrosis. The primary focus of nursing care shifts to preventing devastating secondary complications like pressure injuries (due to immobility and lack of sensation), respiratory issues (if the lesion is high), bladder/bowel dysfunction, and deep vein thrombosis.

Incorrect Options:

A: While physical therapy is crucial for maximizing residual function, myelomalacia implies irreversible damage, so full restoration of motor function is unlikely.

B: Autonomic dysreflexia and spasticity are more common in clients with spinal cord injury who retain some neural pathways, not typically in severe, necrotic myelomalacia leading to flaccid paralysis.

D: Corticosteroids are sometimes used acutely in spinal cord injury to reduce inflammation, but they do not reverse established myelomalacia (necrosis).

The nurse is assessing a client with suspected myelomalacia following a spinal cord injury. Which diagnostic test is most likely to confirm the diagnosis and assess the extent of spinal cord damage?

A. X-ray of the spine

B. Electromyography (EMG)

C. Magnetic Resonance Imaging (MRI) of the spine

D. Nerve Conduction Study (NCS)

Correct Answer: C MRI of the spine is the gold standard for visualizing soft tissues, including the spinal cord. It can reveal areas of edema, hemorrhage, and necrosis (myelomalacia), providing detailed information about the extent and nature of the spinal cord damage.

Incorrect Options:

A: X-rays primarily visualize bone and are good for fractures but show little detail of the spinal cord itself.

B & D: EMG and NCS assess nerve and muscle function, which are useful for evaluating nerve damage but do not directly image the spinal cord's structural integrity or softening.

A client with severe myelomalacia is at high risk for developing neurogenic bladder and bowel. Which nursing action is crucial in managing these complications?

A. Restricting fluid intake to minimize bladder emptying.

B. Initiating a regular bowel and bladder training program.

C. Administering prophylactic antibiotics daily to prevent UTIs.

D. Encouraging the client to delay voiding as long as possible.

Correct Answer: B A structured bowel and bladder training program, including timed voiding/catheterization and bowel regimens, is essential to manage neurogenic bladder and bowel dysfunction, prevent complications like UTIs and constipation/impaction, and promote client dignity.

Incorrect Options:

A: Restricting fluid intake is generally harmful and can lead to dehydration and concentrated urine, increasing UTI risk.

C: Prophylactic antibiotics are generally not recommended for long-term use due to the risk of antibiotic resistance unless there's a specific indication.

D: Delaying voiding can lead to overdistention, increased risk of UTIs, and potential kidney damage. Regular emptying is key.

A nurse is caring for a client diagnosed with hematomyelia. The nurse understands that this condition is characterized by:

A. Bleeding within the subdural space of the spinal cord.

B. The presence of a tumor within the spinal cord.

C. Hemorrhage directly within the spinal cord parenchyma.

D. Inflammation of the meninges surrounding the spinal cord.

Correct Answer: C Hematomyelia specifically refers to bleeding within the substance (parenchyma) of the spinal cord itself. This is distinct from bleeding in the epidural or subdural spaces.

Incorrect Options:

A: This describes a spinal subdural hematoma.

B: This describes a spinal cord tumor.

D: This describes meningitis or myelitis if inflammation is in the cord.

Which of the following is a common cause of atraumatic hematomyelia?

A. A fall from a significant height

B. Anticoagulant therapy in a client with a vascular malformation

C. A severe whiplash injury

D. Osteoarthritis of the spine

Correct Answer: B While trauma can cause hematomyelia, spontaneous (atraumatic) hematomyelia is often linked to underlying vascular malformations (e.g., arteriovenous malformations - AVMs) that rupture, especially in individuals on anticoagulant therapy who have increased bleeding tendencies.

Incorrect Options:

A & C: These are traumatic causes.

D: Osteoarthritis primarily affects the bones and joints and does not directly cause bleeding within the spinal cord.

A client with acute hematomyelia is presenting with sudden onset of severe back pain, ascending sensory loss, and motor weakness. The nurse should prioritize which intervention?

A. Administering a strong opioid analgesic for pain relief.

B. Preparing the client for emergency surgical decompression.

C. Encouraging early ambulation to prevent muscle atrophy.

D. Initiating range-of-motion exercises to affected extremities.

Correct Answer: B Acute hematomyelia, especially when rapidly progressive, constitutes a neurological emergency. Surgical decompression may be necessary to remove the hematoma, relieve pressure on the spinal cord, and prevent further neurological damage.

Incorrect Options:

A: While pain relief is important, it's not the highest priority when rapid neurological deterioration is occurring.

C & D: Early ambulation and ROM exercises are typically initiated after neurological stabilization, not during acute, progressive deterioration where movement could worsen injury or pain.

A client diagnosed with hematomyelia is being monitored closely. Which change in assessment findings would indicate an expansion of the hematoma and worsening neurological status?

A. Improvement in muscle strength in the lower extremities.

B. Return of sensation to the affected dermatomes.

C. New onset of respiratory distress and decreased level of consciousness.

D. Decrease in reported back pain.

Correct Answer: C An expanding hematoma can compress the spinal cord more extensively, leading to ascending neurological deficits. If the hematoma expands to affect the cervical region or brainstem (in severe cases), it can impair respiratory drive and consciousness, indicating critical worsening.

Incorrect Options:

A & B: Improvement in muscle strength and sensation would indicate neurological improvement, not worsening.

D: A decrease in reported pain, without other signs of improvement, could indicate nerve damage and loss of sensation, or simply a temporary fluctuation, but it doesn't definitively rule out worsening and shouldn't be the sole indicator of improvement.

The nurse is preparing a client with hematomyelia for discharge. Which instruction is most important for the nurse to include regarding prevention of recurrence?

A. "Avoid any strenuous activity for at least six months."

B. "Ensure you get adequate rest and sleep daily."

C. "Adhere strictly to your prescribed anticoagulant regimen and report any bleeding signs."

D. "Increase your intake of calcium-rich foods to strengthen your spine."

Correct Answer: C If the hematomyelia was linked to anticoagulant therapy and/or an underlying vascular malformation, careful management of anticoagulation is paramount. Strict adherence to prescribed dosages and prompt reporting of any bleeding signs are crucial to prevent re-bleeding.

Incorrect Options:

A: While some activity restrictions may be given initially, a blanket "avoid all strenuous activity for six months" is too general and not the most important, especially if a specific cause like a vascular malformation was treated.

B: Adequate rest and sleep are good health practices but not the primary preventative measure for hematomyelia recurrence.

D: Calcium intake is related to bone health, not the prevention of bleeding within the spinal cord.