1.

A 60-year-old male client comes into the emergency department with a complaint of crushing substernal
chest pain that radiates to his shoulder and left arm. The admitting diagnosis is acute myo-cardial infarction
(MI). Immediate admission orders include oxygen by nasal cannula at 4 L/minute, blood work, a chest
radiograph, a 12-lead electrocardiogram (ECG), and 2 mg of morphine sulfate given I.V. The nurse should first:
A. . Administer the morphine.
B.. Obtain a 12-lead ECG.
C. Obtain the blood work.
D. Order the chest radiograph
RATIO: Although obtaining the ECG, chest radio-graph, and blood work are all important, the nurse's priority
action should be to relieve the crushing chest pain. Therefore, administering morphine sulfate is the priority
action.

2. When administering a thrombolytic drug to the client experiencing an MI, the nurse explains to him that the
purpose of the drug is to
A.Help keep him well hydrated
B.Dissolve clots that he may have
C. Prevent kidney failure
D.Treat potential cardiac dysrhythmias
RATIO: Thrombolytic drugs are administered within the first 6 hours after onset of an MI to lyse clots and
reduce the extent of myocardial damage.

3. The nurse is assessing a client who has had an Ml. The nurse notes the cardiac rhythm shown on the ECG
strip. The nurse identifies this rhythm as which of the following?
A. Atrial fibrillation
B. Ventricular tachycardia
C.Premature ventricular contractions (PVCs)
D. Third -degree block

4. The nurse is assessing a client who has had an MI. The nurse notes the cardiac rhythm shown on the ECG
strip. The nurse identifies this rhythm as which of the following?
A. Atrial fibrillation
B. Ventricular tachycardia
C. PVCs
D. Third-degree heart block

5.If the client who was admitted for myocardial infarction (MI) develops cardiogenic shock,
Which characteristic sign should the nurse expect to observe?
A. Oliguria.
B. . Bradycardia.
C. Elevated blood pressure.
D. Fever
RATIO: Oliguria occurs during cardiogenic shock because there is reduced blood flow to the kidneys. Typical
signs of cardiogenic shock include low blood pressure, rapid and weak pulse, decreased urine output, and
signs of diminished blood flow to the brain, such as confusion and restlessness. Cardiogenic shock is a
serious complication of MI, with a mortality rate approaching 90%. Fever is not a typical sign of cardiogenic
shock.

6.The physician orders continuous I.V. nitro-glycerin infusion for the client with myocardial infarction.
Essential nursing actions include which of the following?
A. Obtaining an infusion pump for the medication.
B. Monitoring blood pressure every 4 hours.
C. Monitoring urine output hourly.
D. Obtaining serum potassium levels daily.
RATIO: I.V. nitroglycerin infusion requires an infusion pump for precise control of the medica-tion. Blood
pressure monitoring would be done with a continuous system, and more frequently than every 4 hours.
Hourly urine outputs are not always required. Obtaining serum potassium levels is not associated with
nitroglycerin infusion.

7.When teaching the client with myocardial infarction (MI), the nurse explains that the pain associated with MI
is caused by:
A. Left ventricular overload.
B. Impending circulatory collapse.
C. Extracellular electrolyte imbalances.
D. Insufficient oxygen reaching the heart muscle.
RATIO: An MI interferes with or blocks blood circulation to the heart muscle. Decreased blood supply to the
heart muscle causes ischemia, or poor myocardial oxygenation. Diminished oxygenation or lack of oxygen to
the cardiac muscle results in ischemic pain or angina.

8. Aspirin is administered to the client experiencing an MI because of its

A. Antipyretic action
B. Antithrombotic action
C. Antiplatelet action
D. Analgesic action
RATIO: Aspirin does have antipyretic, antiplatelet, and analgesic actions, but the primary reason ASA is
administered to the client experiencing an MI is its antithrombotic action.

9. While caring for a client who has sustained an MI, the nurse notes eight PVCs in one minute on the cardiac
monitor. The client is receiving an IV infusion of D5W and oxygen at 2 L/minute. The nurse’s first course of
action should be to:
A. Increase the IV infusion rate
B. Notify the physician promptly
C. Increase the oxygen concentration
D. Administer a prescribed analgesic
RATIO: PVCs are often a precursor of life-threatening arrhythmias, including ventricular tachycardia and
ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate greater than
five or six per minute in the post-MI client, the HCP should be notified immediately.

10. Which of the following is an expected outcome for a client on the second day of hospitalized
after an MI? The client
A.Has minimal chest pain
B.Can identify risk factors for MI.
C. Agrees to participate in a cardiac rehabilitation program
D. Can perform personal self-care activities without pain
RATIO: By day 2 of hospitalization after an MI, clients are expected to be able to perform personal care
without chest pain. Severe chest pain should not be present on day 2 after an MI. Day 2 of hospitalization may
be too soon for clients to be able to identify risk factors for MI or to begin a walking program; however, the
client may be sitting up in a chair as part of the cardiac rehabilitation program

11. When teaching a client about the expected outcomes after intravenous administration of furosemide, the
nurse would include which outcome?
A. Increased blood pressure
B. Increased urine output
C. Decreased pain
D. Decreased PVCs
RATIO: Furosemide is a loop diuretic that acts to increase urine output. Furosemide does not increase blood
pressure, decrease pain, or decrease arrhythmias

12. After an MI, the hospitalized client is taught to move the legs about while resting in bed. This
of exercise is recommended primarily to help
A. Prepare the client for ambulation
B. Promote urinary and intestinal elimination
C. Prevent thrombophlebitis and blood clot formation
D. Decrease the likelihood of decubitus ulcer formation
RATIO: Encouraging the client to move the legs while in bed is a preventive strategy taught to all clients who
are hospitalized and on bed rest to promote venous return. The muscular action aids in venous return and
prevents venous stasis in the lower extremities.

13. Which of the following reflects the principle on which a client's diet will most likely be based
during the acute phase of MI?
A. Liquids as desired
B Small, easily digested meals
C. Three regular meals per day
D. Nothing by mouth
RATIO: Recommended dietary principles in the acute phase of MI include avoiding large meals because small.
easily digested foods are better digested foods are better tolerated. Fluids are given according to the client’s
needs. and sodium restrictions may be prescribed. especially for clients with manifestations of heart failure.
Cholesterol restrictions may be ordered as well.

14. Of the following controllable risk factors for coronary heart disease (CAD) appears most closely
linked to the development of the disease?
A. Age
B. Medication usage
C. High cholesterol levels
D. Gender

15. Which of the following is an uncontrollable risk factor that has been linked to the development of
CAD?
A. Exercise
B. Obesity
C. Stress
D. Heredity

16. If a client displays risk factors for CAD such as smoking cigarettes, eating a diet high in saturated
fat, or leading a sedentary lifestyle, techniques of behavior modification may be used to help the
client change behavior. The nurse can best reinforce new adaptive behaviors by
A. Explaining how the old behavior leads to poor health
B. Withholding praise until the new behavior is well established
C. Rewarding the client whenever the acceptable behavior is performed
D. Instilling mild fear into the client to extinguish the behavior
RATIO: A basic principle of behavior modification is that behavior that is learned and continued is behavior
that has been rewarded. Other reinforcement techniques have not been found to be as effective as reward.

17. Alteplase recombinant, or tissue plasminogen activator (1-PA), a thrombolytic enzyme, is

administered during the first 6 hours after onset of MI to
A. Control chest pain
B. Reduce coronary artery vasospasm
C. Control the dysrhythmias associated with MI
D. Revascularize the blocked coronary artery
RATIO: The thrombolytic agent t-PA, administered intravenously, lyses the clot blocking the coronary artery.
The drug is most effective when adminis-tered within the fi rst 6 hours after onset of MI. The drug does not
reduce coronary artery vasospasm; nitrates are used to promote vasodilation. Arrhyth-mias are managed by
antiarrhythmic drugs. Surgical approaches are used to open the coronary artery and reestablish a blood
supply to the area.

18.After the administration of t-PA, the nurse understands that a nursing assessment priority is to
A. Observe the client for chest pain
B. Monitor for fever
C. Monitor the 12-lead ECG every 4 hours
D. Monitor breath sounds
RATIO: Although monitoring the 12-lead ECG and monitoring breath sounds are important, observing the
client for chest pain is the nursing assessment priority because closure of the previously obstructed coronary
artery may recur. Clients who receive t-PA frequently receive heparin to prevent closure of the artery after
administration of t-PA. Careful assessment for signs of bleeding and monitoring of partial thromboplastin
time are essential to detect complications. Administration of t-PA should not cause fever.

19. When monitoring a client who is receiving tissue plasminogen activator (t-PA), the nurse should have
resuscitation equipment available because reperfusion of the cardiac tissue can result in which of the
following?
A. Cardiac arrhythmias.
B. Hypertension.
C. Seizure.
D. Hypothermia.
RATIO: Cardiac arrhythmias are commonly observed with administration of t-PA. Cardiac arrhythmias are
associated with reperfusion of the cardiac tissue. Hypotension is commonly observed with administra-tion of
t-PA. Seizures and hypothermia are not gener-ally associated with reperfusion of the cardiac tissue.

20. Contraindications to the administration of t-PA include which of the following?

A. Age greater than 60 years
B. History of cerebral hemorrhage
C. History of heart failure
D. Cigarette smoking
RATIO: A history of cerebral hemorrhage is a contraindication to administration of t-PA because the risk of
hemorrhage may be further increased. Age greater than 60 years, history of heart failure, and cigarette
smoking are not contraindications.

21. A client has driven himself into the emergency room. He is 50 years old, has a history of
hypertension, and informs the nurse that his father died from a heart attack at 60 years of age
The client is presently complaining of indigestion. The nurse connects him to an EGG monitor and
begins administering oxygen at 2L/min per nasal cannula. The nurse's next action would be to
A. Call for the doctor
B. Start an intravenous line
C. Obtain a portable chest radiograph
D. Draw blood for laboratory studies
RATIO: Advanced cardiac life support recommends that at least one or two intravenous lines be inserted in
one or both of the antecubital spaces.

22. Crackles heard on lung auscultation indicate which of the following?

A Cyanosis
B. Bronchospasm
C. Airway narrowing
D. Fluid-filled alveoli

23. A 68-year-old female client on day 2 after hip surgery has no cardiac history but reports having chest
heaviness. The first nursing action should be to:
A. Inquire about the onset, duration, severity, and precipitating factors of the heaviness.
B. Administer oxygen via nasal cannula.
C. Offer pain medication for the chest heaviness.
D. Inform the physician of the chest heaviness.
RATIO: Further assessment is needed in this situation. It is premature to initiate other actions until further
data have been gathered. Inquiring about the onset, duration, location, severity, and precipitating factors of
the chest heaviness will provide pertinent information to convey to the physician.

24. The nurse receives emergency laboratory results for a client with chest pain and immediately
informs the physician. An increased myoglobin level suggests which of the following?
A. Cancer
B. Hypertension
C. Liver disease
D. Myocardial
RATIO: Detection of myoglobin is one diagnostic tool to determine whether myocardial damage has occurred.
Myoglobin is generally detected about 1 hour after a heart attack is experienced and peaks within 4 to 6 hours
after infarction. Myoglobin does not help diagnose cancer, hypertension, or liver disease.

25. An older, sedentary adult may not respond to emotional or physical stress as well as a younger individual
because of
A. Left ventricular atrophy
B. Irregular heart beats
C. Peripheral vascular occlusion
D. Pacemaker placement
RATIO: In older adults who are less active and do not exercise the heart muscle, atrophy can result. Disuse or
deconditioning can lead to abnormal changes in the myocardium of the older adult. As a result, under
sudden emotional or physical stress, the left ventricle is less able to respond to the increased demands on the
myocardial muscle.

26. A 69-year-old woman has a history of heart failure, She is admitted to the emergency department
with heart failure complicated by pulmonary edema. On admission of this client, which of the following
should be assessed first?
A Blood pressure
B. Skin breakdown
C. Serum potassium
D. Urine output
RATIO: It is a priority to assess blood pressure first because people with pulmonary edema typically
experience severe hypertension that requires early intervention. The client probably does not have skin
breakdown on admission; however, when the client is stable, the nurse should inspect the skin. Potassium
levels are not the first priority. The nurse should monitor urine output after the client is stable.

27. In which of the following positions should the nurse place a client with suspected heart failure?
A. Semi-sitting (low Fowler's)
B. Lying on the right side (Sim's)
C. Sitting almost upright (high Fowler's)
D. Lying on the back with the head lowered (Trendelenburg)
RATIO: Sitting almost upright in bed with the feet and legs resting on the mattress decreases venous return to
the heart, thus reducing myocardial work-load. Also, the sitting position allows maximum space for lung
expansion. Low Fowler's position would be used if the client could not tolerate high Fowler's position for
some reason. Lying on the right side would not be a good position for the client in heart failure. The client in
heart failure would not tolerate the Trendelenburg's position.

28. The major goal of therapy for a client with heart failure and pulmonary edema would be to
A. Increase cardiac output
B. Improve respiratory status
C. Decrease peripheral edema
D. Enhance comfort
RATIO: Increasing cardiac output is the main goal of therapy for the client with heart failure or pulmo-nary
edema. Pulmonary edema is an acute medical emergency requiring immediate intervention. Respi-ratory
status and comfort will be improved when cardiac output increases to an acceptable level.

29. Digoxin is administered intravenously to a client with heart failure, primarily because the drug acts
to
A. Dilate coronary arteries
B. Increase myocardial contractility
C. Decrease cardiac dysrhythmias
D. Decrease electrical conductivity in the heart
RATIO: digoxin is cardiac glycoside with positive inotropic activity. This inotropic activity causes increased
strength of myocardial contractions and thereby increases output of blood from the left ventricle. Digoxin
does not dilate coronary arteries. Although digoxin can be used to treat dysrhythmias and does decrease the
electrical conductivity of the myocardium, this is not the primary reason for its use in clients with heart failure
and pulmonary edema.

30. Captopril, an angiotensin-converting enzyme inhibitor, may be administered to a client with heart
failure because it acts as a
A. Vasopressor
B. Volume expander
C. Vasodilator
D. Potassium-sparing diuretic
RATIO: ACE inhibitors have become the vasodilators of choice in the client with mild to severe congestive
heart failure. Vasodilator drugs are the only class of drugs clearly shown to improve survival in overt heart
failure.

31. Furosemide is administered intravenously to a client with heart failure. How soon after administration
should the nurse begin to see evidence of the drug's desired effect?
A. 5 to 10 minutes
B. 30 to 60 minutes
C. 2 to 4 hours
D. 6 to 8 hours
RATIO: After IV injection of furosemide. diuresis normally begins in about 5 minutes and reaches its peak
within about 30 minutes. Medication effects last 2 to 4 hours.

32. The nurse teaches a client with heart failure to take oral furosemide in the morning. The primary
reason for this is to help
A. Prevent electrolyte imbalances
B. Retard rapid drug absorption
C. Excrete excessive fluids accumulated during the night
D. Prevent sleep disturbances during the night
ANSWER: When diuretics are given early in the day, the client will void frequently during the daytime hours
and will not need to void frequently during the night. Therefore, the client's sleep will not be disturbed.
Taking furosemide in the morning has no effect on preventing electrolyte imbalances or retarding rapid drug
absorption. The client should not accumulate excessive fluids throughout the night.

33. Clients with heart failure are prone to atrial fibrillation. During physical assessment, The nurse would
suspect atrial fibrillation when palpation of the radial pulse reveals
A. Two regular beats followed by on irregular beat
B. An irregular pulse rhythm
C. Pulse rate below 60bpm
D. A weak, thread pulse
RATIO: Characteristics of atrial fi fibrillation include pulse rate greater than 100 bpm, totally irregular rhythm,
and no definite P waves on the ECG. During assessment, the nurse is likely to note the irregular rate and
should report it to the physician. A weak, thready pulse is characteristic of a client in shock. Two regular beats
followed by an irregular beat may indicate a premature ventricular contraction.

34. When teaching the client about complications of atrial fibrillation, the nurse understands that the
complications can be caused by
A. Stasis of blood in the atria
B. Increased cardiac output
C. Decreased pulse rate
D. Elevated blood pressure
35. The nurse should teach the client that signs of digitalis toxicity include which of the following?
A. Skin rash over the chest and back
B. Increased appetite
C. Visual disturbances such as seeing yellow spots
D. Elevated blood pressure
RATIO: Signs of toxicity include blurred vision, nausea, and visual impairment (such as seeing green and
yellow halos). A low potassium level can increase the risk of digoxin toxicity.

36. The nurse should be especially alert for signs and symptoms of digitalis toxicity it sarum levels
indicate that the client has a
A. Low sodium level
B. High glucose level
C. High calcium level
D. Low potassium level
RATIO: A low serum potassium level (hypokalemia) predisposes the client to digitalis toxicity. Because
potassium inhibits cardiac excitability, a low serum potassium level would mean that the client would be
prone to increased cardiac excitability.

37. To help maintain a normal blood serum level of potassium, the client receiving a loop diuretic
should be discouraged to eat such foods as bananas, orange juice, as
A. Spinach
B. Skimmed milk
C. Baked chicken
D. Brown rice

38. The nurse finds the apical impulse below the fifth intercostals space, The nurse suspects
A. Left atrial enlargement
B. Left ventricular enlargement
C. Right atrial enlargement
D. Right ventricular enlargement
RATIO: A normal apical impulse is found under over the apex of the heart and is typically located and
auscultated in the left fifth intercostal space in the midclavicular line. An apical impulse located or
auscultated below the fifth intercostal space or lateral to the midclavicular line may indicate left ventricular
enlargement.

39. The nurse is admitting a 69-year-old man to the clinical unit. The client has a history of left
ventricular enlargement. During the assessment, the nurse notes +3 pitting edema of the ankles
bilaterally. The client does not have chest pain. The nurse observes that the client does have
dyspnea at rest. The nurse infers that the client may have
A. Arteriosclerosis
B. Congestive heart failure
C. Chronic bronchitis
D. Acute myocardial infarction
RATIO: Peripheral edema is a symptom of congestive heart failure. Congestive heart failure results when the
heart chronically pumps against increased resistance or is unable to contract forcefully to pump the blood
out into the systemic circulation. As a result, the ventricles become overfilled and there is an accumulation of
volume within the closed system. The client’s symptoms do not indicate arteriosclerosis, chronic bronchitis,
or acute MI

40. The nurse's discharge teaching plan for the client with congestive heart failure would stress the
significance of which of the following?
A. Maintaining a high fiber diet
B. Walking 2 miles everyday
C. Obtaining daily weights at the same time each day
D. Remaining sedentary for most of the day.

41. A 70-year-old woman is scheduled to undergo mitral valve replacement for severe mitral stenosis
and mitral regurgitation. Although the diagnosis was made during childhood, she did not have symptoms
until 4 years ago. Recently, she noticed increased symptoms, despite daily doses of digoxin and furosemide.
During the initial interview with the client, the nurse would most likely learn that the client's childhood
health history included
A Chicken pox
B. Poliomyelitis
C. Rheumatic fever
D. Meningitis
RATIO: Most clients with mitral stenosis have a history of rheumatic fever or bacterial endocarditis.

42. A woman with severe mitral stenosis and mitral regurgitation has a pulmonary artery catheter inserted.
The physician orders pulmonary artery pressure monitoring, including pulmonary catheter wedge pressures.
The purpose of this is to help assess the
A. Degree of coronary artery stenosis
B. Peripheral arterial pressure
C. Pressure from fluid within the left ventricle
D. Oxygen and carbon dioxide concentration in the bloods

45.Because a client has mitral stenosis and is a prospective valve recipient, the nurse preoperatively assesses
the client's past compliance with medical regimens. Lack of compliance with which of the following regimens
would pose the greatest health hazard to this client?
A. Medication therapy
B. Diet modification
C. Activity restrictions
D. Dental care
RATIO: Preoperatively, anticoagulants may be prescribed for the client with advanced valvular heart disease
to prevent emboli. Post-op, all clients with mechanical valves and some with bioprostheses are maintained
indefinitely on anticoagulation therapy. Adhering strictly to a dosage schedule and observing specific
precautions are necessary to prevent hemorrhage or thromboembolism. Some clients are maintained on
lifelong antibiotic prophylaxis to prevent recurrence from rheumatic fever.

44. In preparing the client and the family for a postoperative stay in the intensive care unit after open
heart surgery, the nurse should explain that
A. The client will remain in the intensive care unit for 5 days
B. The client will sleep most of the time while in the intensive care unit
C. Noise and activity within the intensive care unit are minimal
D. The client will receive medication to relieve pain
RATIO: Management of postoperative pain is a priority for the client after surgery, including valve
replacement surgery. The client and family should be informed that pain will be assessed by the nurse and
medications will be given to relieve the pain. The client will stay in the ICU as long as monitoring and
intensive care are needed.

45. A client who has undergone a mitral valve replacement experiences persistent bleeding from the
surgical incision during the early postoperative period. Which of the following pharmaceutical
agents should the nurse be prepared to administer to this client?
A. Vitamin C
B. Protamine sulfate
C. Quinidine sulfate
D. Warfarin sodium (Coumadin)

46. For a client who excretes excessive amounts of calcium during the postoperative period after
open heart surgery, which of the following measures should the nurse institute to help prevent
complications associated with excessive calcium excretion?
A. Ensure a liberal fluid intake
B. Provide an alkaline-ash die
C. Prevent constipation
D. Enrich the client's diet with dairy products
RATIO: In an immobilized client, calcium leaves the bone and concentrates in the ECF fluid. When a large
amount of calcium passes through the kidneys, calcium can precipitate and form calculi.

47. The nurse teaches the client who is receiving warfarin sodium that
A. Partial thromboplastin time values determine the dosage of warfarin sodium
B. Protamine sulfate is used to reverse the effects of warfarin sodium
C. The international normalized ratio (INR) is used to assess effectiveness
D. Warfarin sodium will facilitate clotting of the blood

48. The nurse teaches her client, who has recently been diagnosed with hypertension, about his
dietary restrictions: a low-calorie, low-fat, low-sodium diet. Which of the following menu selections
would best meet the client's needs?
A. Mixed green salad with blue cheese dressing, crackers, and cold cuts
B. Ham sandwich on rye bread and an orange
C. Baked chicken, an apple, and an slice of while bread
D. Hot dogs, baked beans, and celery and carrot sticks

49. The client realizes the importance of quitting smoking, and the nurse develops a plan to help the
client achieve the goal. Which of the following nursing interventions should be the initial step in
this plan?
A. Review the negative effects of smoking on the body
B. Discuss the effects of passive smoking on environmental pollution
C. Establish the client's daily smoking pattern
D. Explain how smoking worsens high blood pressure
RATIO: A plan to reduce or stop smoking begins with establishing the client's personal daily smoking pattern
and activities associated with smoking. It is important that the client understands the associated health and
environmental risks, but this knowledge has not been shown to help clients change their smoking behavior.

50. Essential hypertension would be diagnosed in a 40-year-old man whose blood pressure readings
were consistently at or above which of the following?
A. 120/90mmHg
B. 130/85mmHa
C. 140/90mmHg
D. 160/80mmHa
RATIO: American Heart Association standards define hypertension as a consistent systolic blood pressure
level greater than 140 mm Hg and a consistent diastolic blood pressure level greater than 90 mm Hg.

51. Which of the following terms refer to the inability to perform previously learned purposeful motor acts
on a voluntary basis?
A. Agraphia
B. Perseveration
C. Agnosia
D. Apraxia
RATIO: Apraxia is inability to execute purposeful, previously learned motor tasks, despite physical ability and
willingness, as a result of brain damage.

52. A nurse is working with a student nurse who is caring for a client with an acute bleeding cerebral
aneurysm. Which action by the student nurse requires further intervention?
A. Maintaining the client in a quiet environment
B. Keeping the client in one position to decrease bleeding
C. Positioning the client to prevent airway obstruction
D. Administering I.V. fluid as ordered and monitoring the client for signs of fluid volume excess
RATIO: The student nurse shouldn't keep the client in one position. She should carefully reposition the client
often (at least every hour). The client needs to be positioned so that a patent airway can be maintained. Fluid
administration must be closely monitored to prevent complications such as increased intracranial pressure.
The client must be maintained in a quiet environment to decrease the risk of rebleeding.
53. Which of the following deficits would the nurse expect during assessment?
A client has experienced an ischemic stroke that has damaged the lower motor neurons al the brain
A Limited attention span and forgetfulness
B. Visual agnosia
C. Auditory agnosia
D. Lack of deep tendon reflexes
RATIO: Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can
cause auditory agnosia. If damage has occurred to the frontal lobe, learning capacity, memory, or other
higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited
attention span, difficulties in comprehension, forgetfulness, and lack of motivation. Damage to the lower
motor neurons may cause decreased muscle tone, flaccid muscle paralysis, and a decrease in or loss of
reflexes.

54. A nurse knows that, for a patient with an ischemic stroke, tPA is contraindicated if the blood pressure
reading is:
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 nim Hg
RATIO: Elevated blood pressure (systolic >185; diastolic >110 mm Hg) is a contraindication to tPA.

55. A patient who has suffered a stroke begins having complications regarding spasticity in the lower
extremity. What ordered medication does the nurse administer to help alleviate this problem?
A. Pregabalin (Lyrica)
B. Diphenhydramine (Benadryl)
C. Heparin
D. Lioresal (Baclofen)
RATIO: Spasticity, particularly in the hand, can be a disabling complication after stroke. Botulinum toxin type
A injected intramuscularly into wrist and finger muscles has been shown to be effective in reducing this
spasticity (although the effect is temporary, typically lasting 2 to 4 months)

56. A patient diagnosed with a stroke is ordered to receive warfarin (Coumadin). Later, the nurse learns
that the warfarin is contraindicated and the order is canceled. The nurse knows that the best alternative
medication to give is which of the following?
A. Ticlopidine(Ticlid)
B. Dipyridamole (Persantine)
C. Clopidogrel (Plavix)
D. Aspirin
RATIO: If warfarin is contraindicated, aspirin is the best option, although other medications may be used if
both are contraindicated.

57. Which of the following is the most common side effect of tissue plasminogen activator (PA)?
A. Increased intracranial pressure (ICP)
B. Hypertension
C.Headache
D. Bleeding
RATIO: Bleeding is the most common side effect of tPA. The patient is closely monitored for bleeding (at IV
insertion sites, gums, urine/stools, and intracranially by assessing changes in level of consciousness).
Headache, increased ICP, and hypertension are not side effects of tPA.

58. Which of the following antiseizure medication has been found to be effective for post-stroke pain?
A. Carbamazepine (Tegretol)
B. Lamotrigine (Lamictal)
C. Topiramate (Topamax)
D. Phenytoin (Dilantin)
RATIO: The antiseizure medication lamotrigine (Lamictal) has been found to be effective for post-stroke pain.

59. The nurse practitioner advises a patient who is at high risk for a stroke to be vigilant in his medication
regime, to maintain a healthy weight, and to adopt a reasonable exercise program. This advice is based
on research data that shows the most important risk factor for stroke is:
A. Dyslipidemia
B. Obesity
C. Hypertension
D. Smoking
RATIO: Hypertension is the most modifiable risk factor for either ischemic or hemorrhagic stroke.
Unfortunately, it remains under-recognized and undertreated in most communities.

60. While providing information to a community group, the nurse tells them the primary initial symptoms of
a hemorrhagic stroke are;
A. Fooldrop and external hip rotation
B. Severe headache and early change in level of consciousness
C. Confusion or change in mental status
D. Weakness on one side of the body and difficulty with speech
RATIO: The main presenting symptoms for ischemic stroke are numbness or weakness of the face, arm, or leg,
especially on one side of the body, confusion or change in mental status, and trouble speaking or
understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are
early signs of a hemorrhagic stroke. Footdrop and external hip rotation can occur if a stroke victim is not
turned or positioned correctly.

61. A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an
infarct. The nurse understands these symptoms to be suggestive of which of the following findings?
A. Left-sided cerebrovascular accident (CVA)
B. Completed Stroke
C. Transient ischemic attack (TIA)
D. Right-sided cerebrovascular accident (CVA)
RATIO: When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the
speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not
enough information to determine if the stroke is still evolving or is complete.

62. A physician orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse
question?
A. Phenytoin (Dilantin)
B. Methyldopa (Aldomet)
C. Heparin sodium
D. Dexamethasone (Decadron)
RATIO: Administering heparin, an anticoagulant, could increase the bleeding associated with hemorrhagic
stroke. Therefore, the nurse should question this order to prevent additional hemorrhage in the brain. In a
client with hemorrhagic stroke, the physician may use dexamethasone to decrease cerebral edema and
pressure; methyldopa, to reduce blood pressure; and phenytoin, to prevent seizures.

63. The nurse caring for a client with a history of transient ischemic attacks (TIAs) is reviewing
medications ordered to prevent a stroke Which medication therapy requires follow-up?
A. Thiazide diuretic
B. Anticoagulant
C. Antiplatelet
D. Beta blocker
RATIO: Even though beta blockers are useful in lowering blood​pressure, they are very limited in preventing
stroke. Anticoagulants and antiplatelets are used to reduce the risk of stroke in clients with TIAs.
Hypertension is the leading cause of stroke. Research indicates that thiazide diuretics and certain other
antihypertensives are useful in reducing stroke risk.

64. Which description of an acute embolic stroke given by the nurse is most accurate?
A. The local cerebral tissue becomes engorged with blood from a ruptured cerebral vessel.
B. A blood clot lodges in a cerebral vessel and blocks blood flow
C. Infarcted areas in the brain slough off, leaving cavities in the brain tissue
D. Cerebral vascular pressure exceeds the elasticity of the vessel wall, resulting in hemorrhages.
RATIO: In embolic​stroke, a blood clot or other matter traveling through cerebral blood vessels becomes
lodged in a narrow vessel blocking blood flow. The area of the brain supplied by the blocked vessel becomes
ischemic. The clot may originate from a thrombus formed in the left side of the heart during atrial​fibrillation,
bacterial​endocarditis, recent myocardial infarction​(MI), atherosclerotic plaque from the carotid​artery,
rheumatic heart​disease, or ventricular aneurysm. Infarcted areas of the brain become ischemic but do not
slough off.

65. The nurse is teaching a class about the causes of a hemorrhagic stroke. Which should the nurse
include?
A. Ruptured aneurysm in the brain
B. Rupture of a fragile arterial vessel in the brain
C. Traumatic injury to the brain
D. All of the above
RATIO; Arterial bleeds in the brain cause hemorrhagic stroke. Blood enters the brain and puts pressure on
brain tissue. Manifestations occur suddenly because of the rapid rise in intracranial pressure​(ICP). Aneurysms
in the brain enlarge over time. This causes the arterial walls to become thin and subject to rupturing. Falls
and other traumatic injuries can cause the arterial walls to rupture. This causes intracranial bleeding with
accompanying increased ICP. Stroke caused by traumatic injury has the poorest outcome with greater
likelihood of death.

66. The nurse is teaching a client about the cause of a transient ischemic attack (TIA). Which should the
nurse include?
A. Brief period of a neurologic deficit
B. Vascular blockage
C. Sudden intracranial bleed
D. Formation of a clot in a blood vessel
RATIO: A TIA is a type of ischemic stroke resulting from a localized neurologic deficit lasting 24 hours or less.
Vascular blockage is the cause of an embolic stroke. Intracranial bleeds cause hemorrhagic strokes. A
thrombotic stroke is the result of the formation of a clot in a blood vessel.

67. A client was diagnosed with a thrombotic stroke of the vertebral artery. Which assessment does the
nurse expect to make?
A. Stupor
B. Global aphasia
C. Contralateral paralysis
D.Dysphagia
RATIO: Dysphagia is the clinical manifestation that is associated with a stroke that affects the vertebral artery.
The other clinical manifestations are seen with internal carotid and middle cerebral artery involvement.

68. An adult client had a stroke involving the internal carotid artery of the dominant hemisphere. The
nurse should anticipate that the client will have difficulty with which function?
A. Speaking
B. Staying alert
C. Retaining urine
D. Swallowing
RATIO: Clinical manifestations of a stroke involving the internal carotid artery include contralateral paralysis
of face and​limbs, contralateral sensory deficits of face and​limbs, aphasia,​apraxia, agnosia, unilateral​
neglect, and homonymous hemianopia. Difficulty​swallowing, drowsiness, and urine retention are not
expected in this type of stroke.

69. A patient presents to the emergency room with complaints of having an "exploding headache" for the
last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a
stroke. Which of the following is a possible cause based on the characteristic symptom?
A. Cerebral aneurysm
B. Cardiogenic emboli
C. Large artery thrombosis
D. Small artery thrombosis
RATIO: A cerebral aneurysm is a type of hemorrhagic stroke that is characterized by an exploding headache.

70. After a patient experienced a brief episode of tinnitus, diplopia, and dysarthria with no residual effects,
the nurse anticipates teaching the patient about
A. cerebral aneurysm clipping.
B. heparin intravenous infusion.
C. oral low-dose aspirin therapy.
D. tissue plasminogen activator (tPA).
RATIO: The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit
platelet aggregation are prescribed after a TIA to prevent stroke

71. A 68-year-old patient is being admitted with a possible stroke. Which information from the assessment
indicates that the nurse should consult with the health care provider before giving the prescribed aspirin?
A. The patient has dysphasia.
B. The patient has atrial fibrillation.
C. The patient reports that symptoms began with a severe headache.
D. The patient has a history of brief episodes of right-sided hemiplegia.
RATIO: A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated.
Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so
the nurse can administer the aspirin.

72.A 73-year-old patient with a stroke experiences facial drooping on the right side and right-sided arm and
leg paralysis. When admitting the patient, which clinical manifestation will the nurse expect to find?
A. Impulsive behavior
B. Right-sided neglect
C. Hyperactive left-sided tendon reflexes
D. Difficulty comprehending instructions
RATIO: Right-sided paralysis indicates a left-brain stroke, which will lead to difficulty with comprehension and
use of language. The left-side reflexes are likely to be intact. Impulsive behavior and neglect are more likely
with a right-side stroke.

73. During the change of shift report a nurse is told that a patient has an occluded left posterior cerebral
artery. The nurse will anticipate that the patient may have
A. dysphasia.
B. confusion.
C. visual deficits.
D. poor judgment.
RATIO: Visual disturbances are expected with posterior cerebral artery occlusion. Aphasia occurs with middle
cerebral artery involvement. Cognitive deficits and changes in judgment are more typical of anterior cerebral
artery occlusion.

74. When teaching about clopidogrel (Plavix), the nurse will tell the patient with cerebral atherosclerosis
A. to monitor and record the blood pressure daily.
B. to call the health care provider if stools are tarry.
C. that clopidogrel will dissolve clots in the cerebral arteries.
D. that clopidogrel will reduce cerebral artery plaque formation.
RATIO: Clopidogrel inhibits platelet function and increases the risk for gastrointestinal bleeding, so patients
should be advised to notify the health care provider about any signs of bleeding. The medication does not
lower blood pressure, decrease plaque formation, or dissolve

75. A patient with carotid atherosclerosis asks the nurse to describe a carotid endarterectomy. Which
response by the nurse is accurate?
A. “The obstructing plaque is surgically removed from an artery in the neck."
B "The diseased portion of the artery in the brain is replaced with a synthetic graft."
C. "A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are
removed."
D.*A catheter with a deflated balloon is positioned at the narrow area, and the balloon is inflated to
flatten the plaque."
RATIO: In a carotid endarterectomy, the carotid artery is incised and the plaque is removed. The response
beginning, "The diseased portion of the artery in the brain is replaced" describes an arterial graft procedure.

76. A patient admitted with possible stroke has been aphasic for 3 hours and his current blood pressure
(BP) is 174/94 mm Hg. Which order by the health care provider should the nurse question?
A. Keep head of bed elevated at least 30 degrees,
B. Infuse normal saline intravenously at 75 mL/hr.
C. Administer tissue plasminogen activator ((PA) per protocol.
D. Administer a labetalol (Normodyne) drip to keep BP less than 140/90 mm Hg.
RATIO: Because elevated BP may be a protective response to maintain cerebral perfusion, antihypertensive
therapy is recommended only if mean arterial pressure (MAP) is >130 mm Hg or systolic pressure is >220 mm
Hg. Fluid intake should be 1500 to 2000 mL daily to maintain cerebral blood flow. The head of the bed should
be elevated to at least 30 degrees, unless the patient has symptoms of poor tissue perfusion. tPA may be
administered if the patient meets the other criteria for tPA use.

77. A 56-year-old patient arrives in the emergency department with hemiparesis and dysarthria that
started 2 hours previously, and health records show a history of several transient ischemic attacks (TIAS)
The nurse anticipates preparing the patient for
A. surgical endarterectomy:
B. transluminal angioplasty.
C. intravenous heparin administration.
D. tissue plasminogen activator ((PA) infusion.
RATIO: The patient's history and clinical manifestations suggest an acute ischemic stroke and a patient who is
seen within 4.5 hours of stroke onset is likely to receive tPA (after screening with a CT scan). Heparin
administration in the emergency phase is not indicated. Emergent carotid transluminal angioplasty or
endarterectomy is not indicated for the patient who is having an acute ischemic stroke.

78. A female patient who had a stroke 24 hours ago has expressive aphasia. The nurse identifies the
nursing diagnosis of impaired verbal communication. An appropriate nursing intervention to help the
patient communicate is to
A. ask questions that the patient can answer with 'yes" or "no."
B. develop a list of words that the patient can read and practice reciting.
C. have the patient practice her facial and tongue exercises with a mirror,
D. prevent embarrassing the patient by answering for her if she does not respond.
RATIO: Communication will be facilitated and less frustrating to the patient when questions that require a
"yes" or "no" response are used. When the language areas of the brain are injured, the patient might not be
able to read or recite words, which will frustrate the patient without improving communication. Expressive
aphasia is caused by damage to the language areas of the brain, not by the areas that control the motor
aspects of speech. The nurse should allow time for the patient to respond.

79. A 72-year-old patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg
daily. When the nurse is administering medications, the patient says, "I don't need the aspirin today. I don't
have a fever." Which action should the nurse take?
A. Document that the aspirin was refused by the patient.
B. Tell the patient that the aspirin is used to prevent a fever.
C. Explain that the aspirin is ordered to decrease stroke risk.
D. Call the health care provider to clarify the medication order.
RATIO: Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the
patient's refusal to take the medication is an inadequate response by the nurse. There is no need to clarify the
order with the health care provider. The aspirin is not ordered to prevent aches and pains.

80. For a patient who had a right hemisphere stroke the nurse establishes a nursing diagnosis of
A. risk for injury related to denial of deficits and impulsiveness
B.impaired physical mobility related to right-sided hemiplegia.
C. impaired verbal communication related to speech-language deficits.
D. ineffective coping related to depression and distress about disability
RATIO: The patient with right-sided brain damage typically denies any deficits and has poor impulse control,
leading to risk for injury when the patient attempts activities such as transferring from a bed to a chair.
Right-sided brain damage causes left hemiplegia. Left-sided brain damage typically causes language deficits.
Left-sided brain damage is associated with depression and distress about the disability.
81. When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke,
which intervention should the nurse include in the plan of care?
A. Apply an eye patch to the right eye.
B. Approach the patient from the right side.
C. Place objects needed on the patient's left side.
D. Teach the patient that the left visual deficit will resolve.
RATIO: During the acute period, the nurse should place objects on the patient's unaffected side. Because
there is a visual defect in the right half of each eye, an eye patch is not appropriate. The patient should be
approached from the left side. The visual deficit may not resolve, although the patient can learn to
compensate for the defect.

82. A 50-year-old patient with a left-brain stroke suddenly bursts into tears when family members visit.
A. use a calm voice to ask the patient to stop the crying behavior.
B. explain to the family that depression is normal following a stroke
C. have the family members leave the patient alone for a few minutes.
D. teach the family that emotional outbursts are common after strokes.
RATIO: Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily
related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the
patient's outburst suggests that depression is not the major cause of the behavior. The family should stay
with the patient. The crying is not within the patient's control and asking the patient to stop will lead to
embarrassment.

83.The nurse identifies the nursing diagnosis of imbalanced nutrition: less than body requirements related to
impaired self-feeding ability for a left-handed patient with left-sided hemiplegia. Which intervention should
be included in the plan of care?
A. Provide a wide variety of food choices.
B. Provide oral care before and after meals.
C. Assist the patient to eat with the right hand.
D. Teach the patient the "chin-tuck" technique.
RATIO: Because the nursing diagnosis indicates that the patient's imbalanced nutrition is related to the
left-sided hemiplegia, the appropriate interventions will focus on teaching the patient to use the right hand
for self-feeding. The other interventions are appropriate for patients with other etiologies for the imbalanced
nutrition.

84. 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.
RATIO: Hypertension is the single most important modifiable risk factor. People who drink more than 1 (for
women) or 2 (for men) alcoholic beverages a day may increase risk for hypertension. Physical inactivity and
obesity contribute to stroke risk but not as much as hypertension.
85. A 40-year-old patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which
intervention will be included in the care plan?
A. Apply intermittent pneumatic compression stockings.
B. Assist to dangle on edge of bed and assess for dizziness.
C. Encourage patient to cough and deep breathe every 4 hours.
D. Insert an oropharyngeal airway to prevent airway obstruction.
RATIO: The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral
vasospasm or further bleeding and is at risk for venous thromboembolism (VTE). Activities such as coughing
and sitting up that might increase intracranial pressure (ICP) or decrease cerebral blood flow are avoided.
Because there is no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.

86. A patient who is in hypovolemic shock has the following clinical signs: Heart rate 120
beats/minute, blood pressure 80/55 mmhg and urine output 20ml/hr. After administering an IV fluid
bolus, which of these signs if noted by the healthcare provider is the best indication of improved
perfusion?
A. Heart rate drops to 100 beats/minute.
B. Right atrial pressure increases.
C. Urine output increases to 30mL/hour.
D. Systolic blood pressure increases to 85 mmHg.

87. Nurse Ram, is assigned to a telephone triage. A client called who was stung by a honeybee and is asking
for help. The client reports of pain and localized swelling but has no respiratory distress or other symptoms of
anaphylactic shock. What is the appropriate initial action that the nurse should direct the client to perform?
A. Removing the stinger by scraping it.
B. Applying a cold compress.
C. Taking an oral antihistamine.
D. Calling the 911.

88. Emergency treatment for a client with impending anaphylaxis secondary to hypersensitivity to a
drug should include which of the following actions first?
A. Administering oxygen
B. Inserting an I.V. catheter
C. Obtaining a complete blood count (CBC)
D. Taking vital signs

89. What are some conditions that may precipitate anaphylactic shock?
A. Insects.
B. Food
C. Medicines.
D. All of the above.
90. You're providing care to a patient in anaphylactic shock. What is NOT a typical medical treatment for this
condition, and if ordered the nurse should ask for an order clarification?
A.I V Diphenhydramine
B. Epinephrine
C. Corticosteroids
D. Isotonic intravenous fluids
E. IV Furosemide
RATIO: Furosemide is a loop-diuretic. This medication removes extra fluid from the blood volume. This is NOT
used as treatment in anaphylactic shock. Patients with this condition actually need fluids because of the shift
of fluid from the intravascular space to the interstitial space. All the other medications may be ordered for this
condition depending on the patient's condition.

91. Following the initial care of a client with asthma and impending anaphylaxis from hypersensitivity to a
drug, the nurse should take which of the following steps next?
A. Administer beta-adrenergic blockers,
B. Administer bronchodilators,
C. Obtain serum electrolyte levels.
D. Have the client lie flat in the bed.

92. What is the MOST important step a nurse can take to prevent anaphylactic shock in a patient?
A. Assessing, documenting, and avoiding all the patient allergies
B. Administering Epinephrine
C. Administering Corticosteroids
D. Establishing IV access

93. A patient is having an anaphylactic reaction to an IV medication. What is the FIRST action the nurse should
take?
A. Administer Epinephrine
B. Call a Rapid Reponse
C. Stop the medication
D. Administer a breathing treatment

94. A 65-year-old patient arrived at the triage area with complaints of diaphoresis, dizziness, and
left-sided chest pain. This patient should be prioritized into which category?
A. Non-urgent.
B. Urgent.
C. Emergent.
D. High urgent.

95. What is the BEST position for a patient in anaphylactic shock?

A. Lateral recumbent
B. Supine with legs elevated
C. High Fowler's
D. Semi-Fowler's
RATIO: This position will increase venous return to the heart, which will help increase cardiac output and
blood pressure.

96. You're working on a neuro unit. Which of your patients below are at risk for developing
neurogenic shock? Select all that apply:
A. A 38-year-old with a spinal cord injury at L4.
B. A 42-year-old who has spinal anesthesia.
C. A 25-year-old with a spinal cord injury above T6.
D. A 55-year-old patient who is reporting seeing green halos while taking Digoxin.

97. Anaphylactic shock is associated with which type of hypersensitivity?

A. Type I hypersensitivity.
B. Type I hypersensitivity.
C. Type Ill sensitivity
D. Type V sensitivity

98. Your patient is having a sudden and severe anaphylactic reaction to a medication. You immediately stop
the medication and call a rapid response. The patient's blood pressure is 80/52, heart rate 120, and oxygen
saturation 87%. Audible wheezing is noted along with facial redness and swelling. As the nurse you know that
the first initial treatment for this patient's condition is?
A. IV Diphenhydramine
B. IV Normal Saline Bolus
C. IM Epinephrine
D. Nebulized Albuterol
RATIO: IM or subq Epinephrine is the first-line treatment for anaphylaxis. Epinephrine will cause
vasoconstriction (this will increase the blood pressure and decrease swelling) and bronchodilation (this will
dilate the airways). This patient's cardiovascular and respiratory system is compromised. Therefore,
epinephrine will provide fast relief with anaphylaxis.

99. A 25-year-old female is admitted to the ER in anaphylactic shock due to a bee sting. According
to the patient's mother, the patient is severely allergic to bees and was recently stung by one. This
type of anaphylactic reaction is known as a?
A. Type I Hypersensitivity Reaction
B. Type Il Hypersensitivity Reaction
C. Type Ill Hypersensitivity Reaction
D. Type IV Hypersensitivity Reaction
RATIO: Type I Hypersensitivity Reactions are immediate and cause anaphylaxis. It occurs when an antigen
(the allergen....in this case bee venom) attaches to immunoglobulin E (IgE) antibodies. These antibodies are
created due to this allergen and attach to the mast cells and basophils. This leads to a system-wide release of
inflammatory mediators (histamine and other inflammatory substances). It is important to note a patient
must be sensitized (meaning the immune system has seen the allergen before and produced IgE antibodies in
response to the allergen).
100. A patient with a spinal cord injury is recovering from neurogenic shock. The nurse realizes that
the patient should not develop a full bladder because what emergency condition can occur if it is not
corrected quickly?
A. Autonomic dysreflexia.
B. Autonomic crisis.
C. Autonomic shutdown.
D. Autonomic failure