A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency ...

A 70-year-old female patient with left-sided hemiparesis arrives by ambulance to the emergency department. Which action should the nurse take first?
 
  a. Monitor the blood pressure.
  b. Send the patient for a computed tomography (CT) scan.
  c. Check the respiratory rate and effort.
  d. Assess the Glasgow Coma Scale score.

Question 2

The nurse is caring for a patient who has just returned after having left carotid artery angioplasty and stenting. Which assessment information is of most concern to the nurse?
 
  a. The pulse rate is 102 beats/min.
  b. The patient has difficulty speaking.
  c. The blood pressure is 144/86 mm Hg.
  d. There are fine crackles at the lung bases.

Question 3

The nurse is caring for a patient who has been experiencing stroke symptoms for 60 minutes. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)?
 
  a. Assess the patient's gag and cough reflexes.
  b. Determine when the stroke symptoms began.
  c. Administer the prescribed short-acting insulin.
  d. Infuse the prescribed IV metoprolol (Lopressor).

Question 4

After receiving change-of-shift report on the following four patients, which patient should the nurse see first?
 
  a. A 60-year-old patient with right-sided weakness who has an infusion of tPA prescribed
  b. A 50-year-old patient who has atrial fibrillation and a new order for warfarin (Coumadin)
  c. A 40-year-old patient who experienced a transient ischemic attack yesterday who has a dose of aspirin due
  d. A 30-year-old patient with a subarachnoid hemorrhage 2 days ago who has nimodipine (Nimotop) scheduled

Question 5

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness (LOC). Which nursing diagnosis do they determine has the highest priority for the patient?
 
  a. Impaired physical mobility related to weakness
  b. Disturbed sensory perception related to brain injury
  c. Risk for impaired skin integrity related to immobility
  d. Risk for aspiration related to inability to protect airway

Question 6

Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider?
 
  a. The patient complains of having a stiff neck.
  b. The patient's blood pressure (BP) is 90/50 mm Hg.
  c. The patient reports a severe and unrelenting headache.
  d. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).

Question 7

A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an intracerebral hemorrhage. Which information about the patient is most important to communicate to the health care provider?
 
  a. The patient's speech is difficult to understand.
  b. The patient's blood pressure is 144/90 mm Hg.
  c. The patient takes a diuretic because of a history of hypertension.
  d. The patient has atrial fibrillation and takes warfarin (Coumadin).

Question 8

A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department and diagnostic tests are ordered. Which test should be done first?
 
  a. Complete blood count (CBC)
  b. Chest radiograph (Chest x-ray)
  c. 12-Lead electrocardiogram (ECG)
  d. Noncontrast computed tomography (CT) scan

Question 9

Which stroke risk factor for a 48-year-old male patient in the clinic is most important for the nurse to address?
 
  a. The patient is 25 pounds above the ideal weight.
  b. The patient drinks a glass of red wine with dinner daily.
  c. The patient's usual blood pressure (BP) is 170/94 mm Hg.
  d. The patient works at a desk and relaxes by watching television.