1. Regular oral hygiene is an essential intervention for the client who

• Regular oral hygiene is an essential intervention for the client who

has had a stroke. Which of the following nursing measures is inappropriate when providing oral hygiene?

• Placing the client on the back with a small pillow under the head.
• Keeping portable suctioning equipment at the bedside.
• Opening the client’s mouth with a padded tongue blade.
• Cleaning the client’s mouth and teeth with a toothbrush.
• A 78-year-old client is admitted to the emergency department with

numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority?

• Prepare to administer recombinant tissue plasminogen activator (rt-PA).
• Discuss the precipitating factors that caused the symptoms.
• Schedule for A STAT computer tomography (CT) scan of the head.
• Notify the speech pathologist for an emergency consult.
• A client arrives in the emergency department with an

ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment?

• Current medications.
• Complete physical and history.
• Time of onset of current stroke.
• Upcoming surgical procedures.

• During the first 24 hours after thrombolytic therapy for

ischemic stroke, the primary goal is to control the client’s:

• Pulse
• Respirations

3. Blood pressure

• Temperature
• What is a priority nursing assessment in the first 24 hours after

admission of the client with a thrombotic  stroke?

• Cholesterol level

2. Pupil size and pupillary response

• Bowel sounds
• Echocardiogram
• What is the expected outcome of thrombolytic drug therapy?
• Increased vascular permeability.
• Vasoconstriction.
• Dissolved emboli.
• Prevention of hemorrhage
• The client diagnosed with atrial fibrillation has experienced a

transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge?

• An oral anticoagulant medication.
• A beta-blocker medication.
• An anti-hyperuricemic medication.
• A thrombolytic medication.

• Which client would the nurse identify as being most at risk for

experiencing a CVA?

• A 55-year-old African American male.
• An 84-year-old Japanese female.
• A 67-year-old Caucasian male.
• A 39-year-old pregnant female.
• Which assessment data would indicate to the nurse that the client

would be at risk for a hemorrhagic  stroke?

• A blood glucose level of 480 mg/dl.
• A right-sided carotid bruit.
• A blood pressure of 220/120 mmHg.
• The presence of bronchogenic carcinoma.
• The nurse and unlicensed assistive personnel (UAP) are caring for a

client with right-sided paralysis. Which action by the UAP requires the nurse to intervene?

• The assistant places a gait belt around the client’s waist prior to ambulating.
• The assistant places the client on the back with the client’s head to the side.
• The assistant places her hand under the client’s right axilla to help him/her

move up in bed.

• The assistant praises the client for attempting to perform ADL’s

independently.

• An 18-year-old client is admitted with a closed head injury sustained

in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first?

• Reposition the client to avoid neck flexion
• Administer 1 g Mannitol IV as ordered

• Increase the ventilator’s respiratory rate to 20 breaths/minute
• Administer 100 mg of pentobarbital IV as ordered.
• A client with a subarachnoid hemorrhage is prescribed a 1,000-mg

loading dose of Dilantin IV. Which consideration is most important when administering this dose?

• Therapeutic drug levels should be maintained between 20 to 30 mg/ml.
• Rapid Dilantin administration can cause cardiac arrhythmias.

3. Dilantin should be mixed in dextrose in water before administration.

4. Dilantin should be administered through an IV catheter in the client’s hand.

• A client with head trauma develops a  urine output of 300 ml/hr, dry

skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?

• Evaluate urine specific gravity
• Anticipate treatment for renal failure
• Provide emollients to the skin to prevent breakdown
• Slow down the IV fluids and notify the physician
• When evaluating an ABG from a client with a subdural hematoma,

the nurse notes the PaCO2  is 30 mm Hg. Which of the following responses best describes this result?

• Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure

(ICP).

• Emergent; the client is poorly oxygenated.
• Normal
• Significant; the client has alveolar hypoventilation.