NCLEX STROKE

Which clients are most at risk for a stroke? (Select all that apply.)

1. A 78-year-old with atrial fibrillation

2. A 45-year-old who exercises 5 times per week

3. A 30-year-old with frequent migraines

4. A 60-year-old with hypertension

5. A 55-year-old with diabetes

Correct Answer: 1, 4, 5
Rationale: Atrial fibrillation, hypertension, and diabetes are major risk factors for stroke.

What is the most appropriate nursing intervention when a client experiences a sudden onset of unilateral weakness, facial droop, and slurred speech?

1. Call the rapid response team

2. Elevate the head of the bed

3. Perform a full neurologic assessment

4. Prepare to administer acetaminophen

Correct Answer: 1
Rationale: These are classic signs of a stroke. Immediate action is needed—calling the rapid response team initiates emergency care.

What does the acronym FAST stand for in stroke recognition?

1. Face, Activity, Speech, Time

2. Fall, Arms, Speech, Time

3. Face, Arms, Speech, Time

4. Face, Alertness, Strength, Talking

Correct Answer: 3
Rationale: FAST = Face drooping, Arm weakness, Speech difficulty, Time to call 911.

What is the maximum score for the NIH Stroke Scale (NIHSS), and what does it indicate?

1. 10; mild stroke

2. 20; moderate stroke

3. 25; severe stroke

4. 42; most severe neurologic impairment

Correct Answer: 4
Rationale: The NIHSS maximum score is 42. Higher scores indicate more severe stroke symptoms.

Which statements about ischemic strokes are true? (Select all that apply.)

1. They may be preceded by transient ischemic attacks (TIAs)

2. They are caused by a blockage in a cerebral artery

3. They are the most common type of stroke

4. They cause rapid bleeding in brain tissue

5. They may be treated with thrombolytics

Correct Answer: 2, 3, 5
Rationale: Ischemic strokes result from blockage, are the most common type, and are often treated with tPA (a thrombolytic).

Which type of stroke is often caused by rupture of a cerebral artery?

1. Hemorrhagic stroke

2. Ischemic stroke

3. Lacunar stroke

4. Embolic stroke

Correct Answer: 1
Rationale: Hemorrhagic strokes result from ruptured blood vessels, leading to bleeding in the brain.

A client with a stroke in the right hemisphere may exhibit which symptom?

1. Expressive aphasia

2. Impaired logical thinking

3. Left-sided weakness

4. Language deficits

Correct Answer: 3
Rationale: The right brain controls the left side of the body. A right-sided stroke results in left-sided weakness.

The nurse observes a client with left-sided hemiplegia trying to eat. Which action should be prioritized?

1. Encourage independence

2. Place the food tray on the left side

3. Position the food on the right side of the tray

4. Allow the client to eat without assistance

Correct Answer: 3
Rationale: With left-sided weakness, placing food on the unaffected (right) side makes eating easier and safer.

Which intervention is most appropriate for a client experiencing dysphagia following a stroke?

1. Offer fluids before solid food

2. Encourage coughing during swallowing

3. Consult a speech-language pathologist

4. Give small frequent meals

Correct Answer: 2
Rationale: Coughing during swallowing can help prevent aspiration. It's part of safe swallow techniques.

What is the correct order of nursing actions for a suspected stroke client in the ED?

1. CT scan without contrast

2. Establish IV access

3. Perform neurological assessment

4. Check blood glucose

Correct Answer: 4 - 2 - 1 - 3
Rationale: Rule out hypoglycemia first, then start IV, obtain CT to determine stroke type, and assess neuro status.

What type of stroke is most likely caused by atrial fibrillation?

1. Embolic

2. Hemorrhagic

3. Thrombotic

4. Lacunar

Correct Answer: 1
Rationale: Atrial fibrillation increases the risk of emboli, which can travel to the brain and cause embolic stroke.

The nurse is educating a client with aphasia. What is the best strategy to facilitate understanding?

1. Use short, simple sentences

2. Increase volume when speaking

3. Speak rapidly and clearly

4. Repeat directions multiple times

Correct Answer: 1
Rationale: Aphasia patients benefit from clear, simple communication—short sentences are easiest to understand.

Which cranial nerve is most involved in swallowing?

1. Glossopharyngeal (IX)

2. Olfactory (I)

3. Optic (II)

4. Trigeminal (V)

Correct Answer: 1
Rationale: Cranial nerve IX (glossopharyngeal) controls part of the swallowing mechanism.

What does a score of 35 on the NIH Stroke Scale indicate?

1. No stroke symptoms

2. Mild stroke

3. Moderate stroke

4. Very severe stroke

Correct Answer: 4
Rationale: A score of 35 indicates a very severe stroke. NIHSS >25 usually represents significant impairment.

A client had a stroke affecting the Wernicke’s area. What deficit is most likely?

1. Inability to speak clearly

2. Inability to understand speech

3. Inability to form words

4. Inability to write

Correct Answer: 3
Rationale: Damage to Wernicke’s area results in receptive aphasia, where the client can't comprehend speech.

Which interventions help prevent aspiration in a stroke client with dysphagia? (Select all that apply.)

1. Sit upright at 90 degrees while eating

2. Tuck the chin while swallowing

3. Alternate liquids and solids

4. Provide thickened liquids

5. Encourage rapid chewing

Correct Answer: 1, 2, 4
Rationale: These techniques reduce aspiration risk. Rapid chewing can increase the risk, and alternating textures isn't a primary precaution.

The nurse is providing discharge instructions to a stroke client with right-sided weakness. What instruction is most important?

1. "Wear shoes with rubber soles."

2. "Remove rugs and clutter from walkways."

3. "Sleep on your right side to protect the arm."

4. "Use handrails only on the right side."

Correct Answer: 2
Rationale: Fall prevention is key. Removing rugs and clutter reduces trip hazards for someone with limited mobility.

What is the most important nursing action during the administration of tPA for stroke?

1. Monitor blood pressure frequently

2. Avoid invasive procedures

3. Assess for signs of bleeding

4. Prepare for intubation

Correct Answer: 2
Rationale: tPA increases bleeding risk. Avoiding invasive procedures like IV sticks or foley catheters is critical.

A client with a stroke is emotionally labile, suddenly crying then laughing. What is the nurse’s best response?

1. Distract the client with an activity

2. Explain that emotional outbursts are common

3. Ask why they’re reacting this way

4. Ignore the behavior unless it escalates

Correct Answer: 2
Rationale: Emotional lability is common post-stroke. Reassurance and explanation reduce patient anxiety.

Which clinical manifestation is most concerning in a client recovering from a stroke?

1. Fatigue with physical activity

2. Sudden severe headache

3. Trouble finding words

4. Difficulty concentrating

Correct Answer: 3
Rationale: A sudden return of speech issues could signal a recurrent stroke. It requires urgent evaluation.

Which assessment findings are consistent with a left hemisphere stroke? (Select all that apply.)

1. Right-sided weakness

2. Aphasia

3. Impaired math and language skills

4. Impulsivity

5. Slow and cautious behavior

Correct Answer: 1, 3, 4, 5
Rationale: Left hemisphere strokes affect right body movement and language/math abilities. Clients are often slow and cautious.

The nurse is educating a stroke survivor and caregiver on community resources. Which is most appropriate to include?

1. Local parks and gyms

2. Stroke support groups

3. Memory care clinics

4. Nutrition education programs

Correct Answer: 2
Rationale: Support groups help clients and caregivers cope, share experiences, and access stroke-specific resources.