4. Answer: 3.

Blood pressure

Answers and Rationale

Controlling the blood pressure is critical because an intracerebral hemorrhage is

the major adverse effect of thrombolytic therapy. Blood pressure should be
1. Answer: 1. Placing the client on the back with a small pillow under the

maintained according to physician and is specific to the clients ischemic tissue

head.

needs and risks of bleeding from treatment. Other vital signs are monitored, but
the priority is blood pressure.

A helpless client should be positioned on the side, not on the back. This lateral
position helps secretions escape from the throat and mouth, minimizing the risk

5. Answer: 2. Pupil size and pupillary response

of aspiration.
It is crucial to monitor the pupil size and pupillary response to indicate changes
Option B: It may be necessary to suction, so having suction

around the cranial nerves.

equipment at the bedside is necessary.

Option C: Padded tongue blades are safe to use.

Option D: A toothbrush is appropriate to use.

Option A: Cholesterol level is an assessment to be addressed for

long-term healthy lifestyle rehabilitation.

Option C: Bowel sounds need to be assessed because an ileus

2. Answer: 3. Schedule for A STAT computer tomography (CT) scan of the

head.

or constipation can develop, but is not a priority in the first 24 hours.

Option D: An echocardiogram is not needed for the client with a

thrombotic stroke.
A CT scan will determine if the client is having a stroke or has a brain tumor or
another neurological disorder. This would also determine if it is a hemorrhagic or

6. Answer: 3. Dissolved emboli.

ischemic accident and guide the treatment because only an ischemic stroke can
use rt-PA. This would make (1) not the priority since if a stroke was determined to

Thrombolytic therapy is used to dissolve emboli and reestablish cerebral

be hemorrhagic, rt-PA is contraindicated.

perfusion.

Option A: rt-PA is contraindicated.

Options B and D: Discuss the precipitating factors for teaching would

7. Answer: 1. An oral anticoagulant medication.

Thrombi form secondary to atrial fibrillation. Therefore, an anticoagulant would be

not be a priority and slurred speech would as indicate interference for teaching.

anticipated to prevent thrombi formation; and oral (warfarin [Coumadin]) at

Referring the client for speech therapy would be an intervention after the CVA

discharge versus intravenous.

emergency treatment is administered according to protocol.

3. Answer: 3. Time of onset of current stroke.

Option B: Beta blockers slow the heart rate and lower the blood

pressure.

The time of onset of a stroke to t-PA administration is critical. Administration

Option C: Anti-hyperuricemic medication is given to clients with gout.

within 3 hours has better outcomes.

Option D: Thrombolytic medication might have been given at initial

presentation but would not be a drug prescribed at discharge.

Option A: Current medications are relevant, but the onset of

current stroke takes priority.

Option B: A complete history is not possible in emergency care.

Option D: Upcoming surgical procedures will need to be delay if t-PA

is administered.

8. Answer: 1. A 55-year-old African American male.

African Americans have twice the rate of CVAs as Caucasians; males are more
likely to have strokes than females except in advanced years.

Option B: Orientals have a lower risk, possibly due to their high

Option D: Cancer is not a precursor to stroke.

omega-3 fatty acids.

Option D: Pregnancy is a minimal risk factor for CVA.

10. Answer: 3. The assistant places her hand under the clients right axilla
to help him/her move up in bed.

9. Answer: 3. A blood pressure of 220/120 mmHg.

This action is inappropriate and would require intervention by the nurse because

Uncontrolled hypertension is a risk factor for hemorrhagic stroke, which is a

pulling on a flaccid shoulder joint could cause shoulder dislocation; as always use

ruptured blood vessel in the cranium.

a lift sheet for the client and nurse safety.

Option A: High blood glucose levels could predispose a patient to

ischemic stroke, but not hemorrhagic.

Option B: Bruit in the carotid artery would predispose a client to an

embolic or ischemic stroke.

Options A, B, and D: All the other actions are appropriate.