Question

A client with a recent CVA is receiving an IV Heparin drip. Which lab test must the nurse check frequently?

Answer 1

Correct Answers:

PTT (Partial Thromboplastin Time)

Rationale :

🔵 PTT/aPTT is the laboratory test commonly used to monitor the effect of an unfractionated heparin infusion.

🔵 Heparin works by interfering with the clotting cascade, so the nurse must check that the blood is anticoagulated within the therapeutic range and not excessively thinned.

🔵 Frequent monitoring helps reduce the risk of bleeding complications or under-anticoagulation.

🔵 This is especially important in a client with a recent cerebrovascular accident, because both clot progression and bleeding are serious concerns.

🔵 For an IV heparin drip, PTT/aPTT is the key lab the nurse expects to monitor regularly.

Platelets

🔵 Platelets are important to monitor for heparin-induced thrombocytopenia, but they are not the primary lab used to titrate the heparin drip.

🔵 The nurse still needs PTT/aPTT to assess the anticoagulation effect of the infusion.

INR (International Normalized Ratio)

🔵 INR is mainly used to monitor warfarin therapy, not IV unfractionated heparin.

🔵 It does not provide the routine titration guidance needed for a heparin infusion.

PT (Prothrombin Time)

🔵 PT is also more closely associated with monitoring warfarin and the extrinsic clotting pathway.

🔵 IV heparin is typically followed with PTT/aPTT, not PT.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

Battles sign

Rationale :

🟣 Battle sign is the term used for ecchymosis over the mastoid process.

🟣 It is a classic finding associated with a basilar skull fracture, especially involving the temporal bone.

🟣 This bruising appears behind the ear and suggests significant head trauma.

🟣 The finding is important because it can indicate deeper injury and may occur along with CSF leak, hemotympanum, or cranial nerve deficits.

🟣 The nurse should document this mastoid ecchymosis as Battle sign.

Brudzinski's sign

🟣 Brudzinski's sign is a meningeal irritation sign seen with conditions such as meningitis.

🟣 It is not bruising over the mastoid area.

Racoon eyes

🟣 Raccoon eyes refers to periorbital ecchymosis, or bruising around the eyes.

🟣 The question describes bruising over the mastoid process, which is Battle sign, not raccoon eyes.

Kernig's sign

🟣 Kernig's sign is another meningeal irritation finding.

🟣 It does not describe postauricular bruising from head trauma.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

Unilateral neglect

Rationale :

🟢 Unilateral neglect can occur after traumatic brain injury when one cerebral hemisphere is injured and the client fails to attend to the opposite side of space.

🟢 This problem is well described after brain injury, especially with damage involving the right hemisphere.

🟢 A brain contusion is a traumatic injury to brain tissue and can produce cognitive, behavioral, and perceptual deficits, not just motor findings.

🟢 Unilateral neglect would be a realistic and clinically meaningful neuro assessment finding in this setting.

🟢 For this reason, unilateral neglect is the most likely symptom the nurse may document.

Deep respirations

🟢 Deep respirations are not a classic hallmark finding specifically associated with a brain contusion in this context.

🟢 Neuro injury is more likely to cause altered level of consciousness or focal neurologic deficits than this isolated respiratory description.

Decreased cerebral edema

🟢 Decreased cerebral edema is not a symptom the nurse would document during assessment.

🟢 It is more of an outcome or physiologic state rather than an observed clinical manifestation.

Ipsilateral pupils

🟢 “Ipsilateral pupils” is not a standard symptom description by itself.

🟢 Pupil changes are documented by size, equality, and reaction, not simply by the word ipsilateral.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

Loss of same half of visual fields in each eye

Rationale :

🟠 Homonymous hemianopia means loss of vision in the same half of the visual field in both eyes.

🟠 It commonly occurs after a stroke involving the retrochiasmal visual pathway.

🟠 For example, the client may lose the right half of the field in both eyes or the left half in both eyes.

🟠 This differs from blindness in one entire eye or from peripheral field loss alone.

🟠 Therefore, the correct description is loss of same half of visual fields in each eye.

Loss of all vision in both eyes

🟠 This describes total blindness, not homonymous hemianopia.

🟠 Homonymous hemianopia affects only one corresponding half of the visual field in both eyes.

Loss of complete vision in right eye

🟠 Loss of complete vision in one eye is monocular blindness, which is a different visual deficit.

🟠 Homonymous hemianopia involves both eyes, not just one.

Loss of peripheral vision in each eye

🟠 Peripheral vision loss can occur in other visual disorders, but it does not precisely define homonymous hemianopia.

🟠 The defining feature is loss of the same half of the visual field in both eyes.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

"The obstructing plaque is surgically removed from an artery in the neck."

Rationale :

🔴 A carotid endarterectomy is an operation in which plaque is surgically removed from the carotid artery.

🔴 The carotid arteries are located in the neck and supply blood to the brain.

🔴 Removing the plaque helps restore blood flow and lowers stroke risk in selected clients with carotid artery disease.

🔴 This is an open surgical procedure, not a balloon procedure and not removal of clot from the leg.

🔴 Therefore, the most accurate explanation is that the obstructing plaque is surgically removed from an artery in the neck.

"The diseased portion of the artery in the brain is replaced with a synthetic graft."

🔴 That is not what happens in a standard carotid endarterectomy.

🔴 The procedure involves the carotid artery in the neck, not replacement of a diseased brain artery with a graft.

"A wire is threaded through an artery in the leg to the clots in the carotid artery and the clots are removed."

🔴 This does not describe carotid endarterectomy.

🔴 Endarterectomy is an open neck surgery to remove plaque, not a leg-access clot retrieval procedure.

"A catheter with a deflated balloon is positioned at the narrowed area, and the balloon is inflated to flatten the plaque."

🔴 This describes carotid angioplasty, often with stent placement, rather than carotid endarterectomy.

🔴 The question specifically asks about the surgical plaque-removal procedure.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

Administer prescribed stool softener as ordered

Rationale :

🟡 After a subarachnoid hemorrhage, straining can increase intracranial pressure and should be avoided.

🟡 Stool softeners are commonly prescribed to prevent constipation and reduce Valsalva maneuvers during bowel movements.

🟡 Current references on subarachnoid hemorrhage management specifically include stool softeners or laxatives to prevent straining.

🟡 This is a practical and protective nursing intervention in the early plan of care.

🟡 For this client, administering the prescribed stool softener is the correct intervention.

Assist to dangle on edge of bed and assess for dizziness

🟡 Early activity is not the priority in a client with a ruptured aneurysm and acute subarachnoid hemorrhage.

🟡 The focus is on preventing rebleeding, limiting increased intracranial pressure, and maintaining stability.

Encourage client to cough and deep breathe every four hours

🟡 Coughing can increase intrathoracic and intracranial pressure, which is undesirable in this setting.

🟡 This is not the best routine nursing action for a ruptured cerebral aneurysm.

Insert a nasogastric tube to prevent airway obstruction

🟡 An NG tube is not routinely inserted solely to prevent airway obstruction in this situation.

🟡 The question is asking for a standard supportive intervention, and preventing straining with stool softeners is much more appropriate.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Explain that the aspirin is ordered to decrease stroke risk

Rationale :

⭐ A transient ischemic attack is a warning sign that the client is at higher risk for a future stroke.

⭐ Low-dose aspirin is commonly used as an antiplatelet medication to reduce clot formation and lower that risk.

⭐ The client’s statement shows misunderstanding of aspirin as only a fever medicine, so teaching is needed.

⭐ The nurse should explain the true purpose of the medication in this case, which is stroke prevention.

⭐ Therefore, the correct action is to explain that the aspirin is ordered to decrease stroke risk.

Document that the client refused the aspirin

⭐ Documentation is important, but teaching should come first because the client is refusing based on misunderstanding.

⭐ The nurse should attempt to correct the misconception before simply recording refusal.

Tell the client that the aspirin is used to prevent a fever

⭐ That explanation is incorrect for this clinical situation.

⭐ In a client with prior TIA, aspirin is being used to help reduce ischemic stroke risk.

Call the health care provider to clarify the order

⭐ The order itself is not unclear.

⭐ The issue is the client’s misunderstanding, so the nurse should first provide appropriate education.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

Establish immobilization

Rationale :

🟤 When a spinal injury is possible, the priority is to keep the client still and immobilized to prevent further damage.

🟤 Moving the client before stabilization can worsen spinal cord injury and may cause permanent paralysis or other serious complications.

🟤 First-aid guidance for suspected neck or back injury emphasizes not moving the person and maintaining stabilization.

🟤 Immobilization protects the spine until further assessment and help are available.

🟤 Therefore, the priority nursing action is to establish immobilization.

Lift the client back into bed

🟤 Lifting or moving the client before spinal stabilization can worsen a possible spinal injury.

🟤 The client should be kept still until proper immobilization and evaluation occur.

Call the client's family to report the fall

🟤 Family notification is not the immediate priority when spinal injury is possible.

🟤 The first priority is to protect the client from further neurologic harm.

Administer pain relief medication

🟤 Pain control may become necessary, but it is not the first action when spinal cord injury is suspected.

🟤 The spine must be stabilized first.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Expressive-receptive (global) aphasia

Rationale :

⚫ Global aphasia is the most severe form of aphasia and involves major impairment in both language expression and comprehension.

⚫ A client who is unable to speak and unable to follow directions has deficits in both producing and understanding language.

⚫ NIH sources describe global aphasia as severe difficulty with both producing and comprehending language.

⚫ This fits the assessment findings far better than expressive-only or receptive-only aphasia.

⚫ The nurse should document this as expressive-receptive (global) aphasia.

Expressive aphasia

⚫ Expressive aphasia mainly affects the client’s ability to produce speech, while comprehension is relatively better preserved.

⚫ The client in the question also cannot follow directions, so expressive aphasia alone does not fit.

Language impairment

⚫ “Language impairment” is too broad and nonspecific.

⚫ The question describes a more exact aphasia pattern involving both expression and comprehension.

Receptive aphasia

⚫Receptive aphasia mainly affects understanding of language, while speech may still be fluent though not meaningful.

⚫Because this client is unable both to speak and to follow directions, global aphasia is the better description.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Keep the client NPO and administer IV fluids for hydration as ordered by the health care provider

Rationale :

✨ A client with dysphagia after stroke is at risk for aspiration, including silent aspiration.

✨ Standard stroke care recommends keeping clients NPO until swallowing ability has been assessed.

✨ If the swallow is impaired or a formal swallowing study is pending, hydration is maintained with IV fluids as ordered.

✨ Feeding the client before the swallowing assessment can lead to aspiration pneumonia, poor oxygenation, and further complications.

✨ Therefore, the safest action is to keep the client NPO and provide IV hydration as prescribed.

Feed the client pureed or soft foods while she is sitting in an upright position

✨ Even though upright positioning is helpful, oral intake should not begin before the swallowing study or screening is completed.

✨ Giving food too early may cause aspiration.

Administer a clear liquid diet only, using a nasogastric tube

✨ A clear liquid diet by NG tube is not the standard immediate answer in this scenario.

✨ The safest initial step while awaiting formal swallow evaluation is NPO with ordered IV fluids unless another feeding plan has been prescribed.

Feed the client warm liquids only while she is sitting upright with her body positioned forward

✨ Warm liquids can still be aspirated in a client with post-stroke dysphagia.

✨ No oral intake should be given until swallowing safety has been assessed.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 :
A client with a recent CVA is receiving an IV Heparin drip. Which lab test must the nurse check frequently?

2 :
The client was hit by a car while riding their bicycle and sustained a basilar skull fracture. The nurse notes ecchymosis over the mastoid process. How will the nurse document this finding?

3 :
After being tackled in a football game, the client with a diagnosis of a brain contusion has been admitted to the neurovascular unit. During the assessment process, which symptom is likely to be documented by the nurse?

4 :
The client is experiencing right-sided hemiparesis and homonymous hemianopia due to a CVA What is the visual field defect that this client is experiencing?

5 :
A client with carotid atherosclerosis is scheduled to have a carotid endarterectomy, and asks the nurse about questions about this procedure. Which response by the nurse is the most accurate?

6 :
While initiating a care plan for the client with a ruptured cerebral aneurysm and subarachnoid hemorrhage, which intervention will be included in the care plan?

7 :
An elderly client who has a history of a transient ischemic accident (TIA) has an order for Aspirin 81mg daily. When the nurse is administering the medications, the client says, "I don't need the aspirin today, I don't have a fever". Which action will the nurse take?

8 :
The nurse is called to a client's room who has just fallen out of bed. To prevent a spinal cord injury, which priority treatment will the nurse perform?

9 :
An elderly client is brought into the urgent care clinic by his family. The nurse assesses the client's speech pattern and identifies that they are unable to speak and follow directions. How will the nurse document this finding?

10 :
A geriatric client awaiting a swallowing study by the speech therapist, has sustained a cerebral vascular accident, which has caused them to have dysphagia. What action will the nurse take?

QLexNursing

1 : A client with a recent CVA is receiving an IV Heparin drip. Which lab test must the nurse check frequently?

2 : The client was hit by a car while riding their bicycle and sustained a basilar skull fracture. The nurse notes ecchymosis over the mastoid process. How will the nurse document this finding?

3 : After being tackled in a football game, the client with a diagnosis of a brain contusion has been admitted to the neurovascular unit. During the assessment process, which symptom is likely to be documented by the nurse?

4 : The client is experiencing right-sided hemiparesis and homonymous hemianopia due to a CVA What is the visual field defect that this client is experiencing?

5 : A client with carotid atherosclerosis is scheduled to have a carotid endarterectomy, and asks the nurse about questions about this procedure. Which response by the nurse is the most accurate?

6 : While initiating a care plan for the client with a ruptured cerebral aneurysm and subarachnoid hemorrhage, which intervention will be included in the care plan?

7 : An elderly client who has a history of a transient ischemic accident (TIA) has an order for Aspirin 81mg daily. When the nurse is administering the medications, the client says, "I don't need the aspirin today, I don't have a fever". Which action will the nurse take?

8 : The nurse is called to a client's room who has just fallen out of bed. To prevent a spinal cord injury, which priority treatment will the nurse perform?

9 : An elderly client is brought into the urgent care clinic by his family. The nurse assesses the client's speech pattern and identifies that they are unable to speak and follow directions. How will the nurse document this finding?

10 : A geriatric client awaiting a swallowing study by the speech therapist, has sustained a cerebral vascular accident, which has caused them to have dysphagia. What action will the nurse take?

1 :
A client with a recent CVA is receiving an IV Heparin drip. Which lab test must the nurse check frequently?

2 :
The client was hit by a car while riding their bicycle and sustained a basilar skull fracture. The nurse notes ecchymosis over the mastoid process. How will the nurse document this finding?

3 :
After being tackled in a football game, the client with a diagnosis of a brain contusion has been admitted to the neurovascular unit. During the assessment process, which symptom is likely to be documented by the nurse?

4 :
The client is experiencing right-sided hemiparesis and homonymous hemianopia due to a CVA What is the visual field defect that this client is experiencing?

5 :
A client with carotid atherosclerosis is scheduled to have a carotid endarterectomy, and asks the nurse about questions about this procedure. Which response by the nurse is the most accurate?

6 :
While initiating a care plan for the client with a ruptured cerebral aneurysm and subarachnoid hemorrhage, which intervention will be included in the care plan?

7 :
An elderly client who has a history of a transient ischemic accident (TIA) has an order for Aspirin 81mg daily. When the nurse is administering the medications, the client says, "I don't need the aspirin today, I don't have a fever". Which action will the nurse take?

8 :
The nurse is called to a client's room who has just fallen out of bed. To prevent a spinal cord injury, which priority treatment will the nurse perform?

9 :
An elderly client is brought into the urgent care clinic by his family. The nurse assesses the client's speech pattern and identifies that they are unable to speak and follow directions. How will the nurse document this finding?

10 :
A geriatric client awaiting a swallowing study by the speech therapist, has sustained a cerebral vascular accident, which has caused them to have dysphagia. What action will the nurse take?