easy
client says, “I suddenly developed the worst headache of my life 30 minutes ago.” What is the nurse’s PRIORITY?
A. Give oral acetaminophen
B. Ask about caffeine intake
C. Perform a focused neuro assessment and check BP
D. Reassure and dim the lights
C
Sudden severe headache may indicate hemorrhage → immediate neuro and VS assessment.
increase delay at synapse resulting in diminished sense
beneign essential tremors
ortho hypo.
memory changes
motor system may slow down
The nurse is teaching a community group about stroke. Which statement shows correct understanding?
A. “If symptoms go away on their own, we can wait until morning.”
B. “Sudden trouble speaking or understanding speech is a warning sign.”
C. “Stroke only happens to older people.”
D. “If someone has chest pain, that’s always a stroke.”
B
Speech difficulty is part of FAST; stroke can occur at any age and chest pain is more cardiac.
What is the sequence for the complete neuro exam
mental status, cranial nerve, motor, sensation, reflexes
If your pt has a GCS score of 14, what does this mean?
Mild neuro impairment, need further workup and monitoring
During neuro exam, the patient is unable to maintain balance when standing with feet together and eyes closed. This is a positive:
A. Romberg test
B. Phalen’s test
C. Babinski sign
D. Kernig’s sign
A
Romberg assesses balance and proprioception.
Which are early signs of increased intracranial pressure? (Select all that apply.)
A. Subtle change in level of consciousness
B. Cushing’s triad (irregular respirations, bradycardia, widened pulse pressure)
C. Headache
D. Projectile vomiting without nausea
E. Slight pupillary asymmetry
A, C, E
Early: LOC changes, headache, subtle pupil changes. Cushing’s triad and projectile vomiting are lat
What type of patient will get a screening nuero exam?
A pt who has no significant findings from history
A patient begins to have a tonic-clonic seizure in bed. What is the priority nursing action?
A. Restrain the patient’s arms
B. Insert an oral airway
C. Turn the patient to the side and protect the head
D. Hold the tongue down with a tongue blade
C
Side-lying and head protection maintain airway and prevent injury; never restrain or put objects in the mouth
Which factors put a person at higher risk for stroke? (Select all that apply.)
A. Uncontrolled hypertension
B. Atrial fibrillation
C. Smoking
D. Normal BMI and active lifestyle
E. Diabetes mellitus
A, B, C, E
All are major stroke risk factors; healthy BMI and activity reduce risk.
What is the priority nursing intervention when feeding a client with dysphagia?
A. Place them flat to prevent fatigue
B. Offer thin liquids through a straw
C. Sit them upright and keep them upright after meals
D. Encourage talking while chewing to assess speech
C
Upright positioning reduces aspiration risk; thin liquids and talking increase it.
Which statement from a client is MOST concerning for a possible TIA?
A. “I had a dull headache after work yesterday.”
B. “My right arm felt weak and numb for 10 minutes, then it went away.”
C. “Sometimes I feel tired in the afternoon.”
D. “I felt dizzy when I stood up quickly.”
B
Temporary focal neurologic deficit that resolves → TIA → stroke warning.
A patient cannot close the left eye tightly, and the left side of the mouth droops when asked to smile. Which cranial nerve is likely affected?
A. CN V
B. CN VII
C. CN IX
D. CN XII
B
CN VII (facial) controls facial symmetry and eye closure.
A diabetic client reports burning and numbness in both feet. What is the nurse’s BEST teaching priority?
A. “Walk barefoot at home to toughen your feet.”
B. “Check your feet daily with a mirror for injuries.”
C. “Soak your feet in hot water every night.”
D. “Trim your toenails very short and rounded
B
Neuropathy ↓ sensation → daily inspection is critical; barefoot, hot soaks, and improper trimming are unsafe.
After a seizure, which assessment is MOST important?
A. Ask the patient to recall the seizure experience
B. Assess for orientation, airway patency, and vital signs
C. Provide caffeine for alertness
D. Immediately discharge the patient home
B
Postictal priorities: airway, breathing, circulation, and neuro status.
A client’s GCS drops from 14 to 11 in 1 hour. What is the PRIORITY action?
A. Recheck in 4 hours
B. Notify the provider and assess airway and pupils
C. Document and continue current care
D. Administer prescribed sedative
B
A decline of ≥2 points suggests worsening neuro status, possibly increasing ICP → urgent.
Which finding in an older adult is MOST suggestive of pathologic cognitive decline rather than normal aging?
A. Takes longer to process information
B. Needs lists to remember groceries
C. Forgets how to use the microwave they’ve used for years
D. Occasionally misplaces glasses
C
Loss of previously learned skills = concerning for dementia.
A patient arrives with facial droop and slurred speech that began 30 minutes ago. What is the FIRST test likely needed?
A. MRI with contrast
B. Non-contrast CT of the head
C. EEG
D. Carotid ultrasound
B
Rapid non-contrast CT differentiates ischemic vs hemorrhagic stroke before tPA.
A client had a left-hemisphere stroke. Which findings would the nurse expect? (Select all that apply.)
A. Right-sided weakness
B. Left-sided neglect
C. Expressive aphasia
D. Impulsive behavior and poor judgment
E. Difficulty understanding language
A, C, E
Left brain controls language and right body; neglect and impulsivity are more typical of right-hemisphere str
s&s of ischmeic stroke?
one sided weakness,facail droop, aphasia,slurry speech, vision changes, (fast)
What causes ishemic stroke vs hemmorgic
Ischemic=blocked blood flow from thrombotic or embolic
Hemmorgic:bleeding from ruptured vessel
If pt has hyperreflexia when checking DTR that indicates? if they have hyporeflexia?
hyper-stroke(UMN)
hypo-spinal injury/nueropathy(LMN)
A head-injury patient becomes increasingly drowsy, with unequal pupils and vomiting. What is the nurse’s best intervention?
A. Lower the head of the bed
B. Keep the patient flat and encourage coughing
C. Elevate the head of bed to 30 degrees and notify provider
D. Give large fluid bolus
C
Signs of ↑ICP; elevate HOB to promote venous drainage and call provider.
intervention for a pt w alzheimers?
maintain routine
reorient pt
promote independence w ADLS
Nuero rechecks
Stroke prevention?
Manage HTN
ETOH Levels
Manage CKD, DM, diet
Med compliance