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 d epartment with

numbness and weakness of the left arm and slurred speech. W hich 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 o f 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.

Downloaded by zena ahmad ([email protected]) lOMoARcPSD|35287698

• During the first 24 hours after thrombolytic therapy fo r

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

• Pulse
• Respirations
• Blood pressure
• Temperature
• What is a priority nursing assessment in the first 24 ho urs after

admission of the client with a thrombotic stroke?

• Cholesterol level
• Pupil size and pupillary response
• Bowel sounds
• Echocardiogram
• What is the expected outcome of thrombolytic drug ther apy?
• Increased vascular permeability.
• Vasoconstriction.
• Dissolved emboli.
• Prevention of hemorrhage
• The client diagnosed with atrial fibrillation has exp erienced a

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

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

Downloaded by zena ahmad ([email protected]) lOMoARcPSD|35287698

• Which client would the nurse identify as being most at ri sk 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 he ad 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

Downloaded by zena ahmad ([email protected]) lOMoARcPSD|35287698

• 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.
• Dilantin should be mixed in dextrose in water before administration.
• 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 initial ly?

• 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 hemat oma,

the nurse notes the PaCO2 is 30 mm Hg. Which of the followi ng 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.

Downloaded by zena ahmad ([email protected]) lOMoARcPSD|35287698