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STUVIA 2024/2025STROKE- NCLEX
"Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the
degree of blockage, and the availability of collateral circulation."
Clinical manifestations following a stroke are highly variable and depend on the area of the cerebral
cortex and the affected hemisphere, the degree of blockage (total, partial), and the presence or
absence of adequate collateral circulation. (Collateral circulation is circulation formed by smaller
blood vessels branching off from or near larger occluded vessels.) Clinical manifestations of a stroke
do not depend on the cardiovascular health of the client or how quickly the clot can be dissolved.
Clinical manifestations of a stroke are not "general" but individual. - ✔✔During a class on stroke, a
junior nursing student asks what the clinical manifestations of stroke are. What would be the
instructor's best answer?
a) "Clinical manifestations of a stroke depend on the area of the cortex, the affected hemisphere, the
degree of blockage, and the availability of collateral circulation."
b) "Clinical manifestations of a stroke generally include aphasia, one-sided flaccidity, and trouble
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swallowing."
c) "Clinical manifestations of a stroke depend on how quickly the clot can be dissolved."
d) "Clinical manifestations of a stroke are highly variable, depending on the cardiovascular health of
the client."
• Asymptomatic carotid stenosis
• Atrial fibrillation
• Diabetes (associated with accelerated atherogenesis)
• Dyslipidemia
• Excessive alcohol consumption
• Hypercoagulable states
• Hypertension (controlling hypertension, the major risk factor, is the key to preventing stroke)
• Migraine
• Obesity
• Sedentary lifestyle
• Sleep apnea
• Smoking - ✔✔Name three modifiable risk factors for an Ischemic Stroke.
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1 to 3 days
The acute phase of an ischemic stroke may last 1 to 3 days, but ongoing monitoring of all body
systems is essential as long as the patient requires care. - ✔✔A patient is in the acute phase of an
ischemic stroke. How long does the nurse know that this phase may last?
a) Up to 1 week
b) Up to 24 hours
c) 1 to 3 days
d) Up to 2 weeks
190 mm Hg/120 mm Hg
Elevated blood pressure (systolic >185; diastolic >110 mm Hg) is a contraindication to tPA. - ✔✔A
nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure
reading is:
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a) 170 mm Hg/105 mm Hg
b) 185 mm Hg/110 mm Hg
c) 190 mm Hg/120 mm Hg
d) 175 mm Hg/100 mm Hg
2. Face the patient and establish eye contact.
3. Speak in a clear, unhurried manner, and normal tone of voice.
4. Use short phrases, and pause between phrases to allow the patient time to understand what is
being said.
5. Limit conversation to practical and concrete matters.
6. Use gestures, pictures, objects, and writing.
7. As the patient uses and handles an object, say what the object is. It helps to match the words with
the object or action.
8. Be consistent in using the same words and gestures each time you give instructions or ask a
question.
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9. Keep extraneous noises and sounds to a minimum. Too much background noise can distract the
patient or make it difficult to sort out the message being spoken. - ✔✔Name two more "tips' in
communicating with a patient with Aphasia:
4:00 p.m.
Tissue plasminogen activator (tPA) must be given within 3 hours after symptom onset. Therefore,
since symptom onset was 1:00 pm, the window of opportunity ends at 4:00 pm. - ✔✔A patient is
admitted via ambulance to the emergency room of a stroke center at 1:30 p.m. with symptoms that
the patient said began at 1:00 p.m. Within 1 hour, an ischemic stroke had been confirmed and the
doctor ordered tPA. The nurse knows to give this drug no later than what time?
a) 5:30 p.m.
b) 3:00 p.m.
c) 4:00 p.m.
d) 2:30 p.m.
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A unit of fresh frozen plasma is infusing.
FFP is usedin the treatment of clotting deficiencies as seen with over dose of anticoagulants and
would indicate a hemorrhagic stroke. Neuro checks ordered every 2 hours does not differentiate
between types of strokes. Focal seizures can occur with any stroke and would not differentiate.
Suctioning is a nursing action taken to maintain airway and does not indicate a specific type of stroke.
- ✔✔A client is admitted to the intensive care unit (ICU) with a diagnosis of cerebrovascular accident
(CVA). Which assessment by the nurse provides the most significant finding in differentiating between
ischemic and hemorrhagic strokes?
a) Oropharyngeal suctioning as needed.
b) Kepprais ordered for treatment of focal seizures.
c) A unit of fresh frozen plasma is infusing.
d) Neurological checks are ordered every 2 hours.
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a. 6.3 mg - bolus
56.7mg- infusion dose - ✔✔14. A 154-pound woman has been prescribed tPA (0.9 mg/kg) for an
ischemic stroke. The nurse knows to give how many mg initially?
a. 6.3 mg
b. 7.5 mg
c. 8.3 mg
d. 10 mg
a. A 60-year-old African-American man - ✔✔6. A nurse is assisting with a community screening for
people at high risk for stroke. To which of the following clients would the nurse pay most attention?
a. A 60-year-old African-American man
b. A 40-year-old Caucasian woman
c. A 62-year-old Caucasian woman
d. A 28-year-old pregnant African-American woman
a. Heparin sodium - ✔✔16. A physician orders several drugs for a client with hemorrhagic stroke.
Which drug order should the nurse question?
a. Heparin sodium
b. Dexamethasone (Decadron)
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c. Methyldopa (Aldomet)
d. Phenytoin (Dilantin)
a. Intracranial hemorrhage - ✔✔11. Which of the following is a contraindication for the administration
of tissue plasminogen activator (t-PA)?
a. Intracranial hemorrhage
b. Ischemic stroke
c. Age 18 years of age or older
d. Systolic blood pressure less than or equal to 185 mm Hg
a. Left visual field deficit - ✔✔15. What clinical manifestations does the nurse recognize when a
patient has had a right hemispheric stroke?
a. Left visual field deficit
b. Aphasia
c. Slow, cautious behavior
d. Altered intellectual ability
a. She is taking coumadin. - ✔✔9. An emergency department nurse is interviewing a client with signs
of an ischemic stroke that began 2 hours ago. The client reports that she had a cholecystectomy 6
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