Stroke recognition and time-critical management are core med-surg competencies the CMSRN tests. Practice the ischemic-vs-hemorrhagic, tPA, and NIH Stroke Scale scenarios below with full rationales.
Question 1
Post-operative day 3, a patient with COPD develops unilateral arm swelling around a PICC line. Ultrasound confirms deep vein thrombosis. Which anticoagulation choice is optimal?
- A) A) Enoxaparin 1mg/kg twice daily✓
- B) B) Warfarin with goal INR 2-3
- C) C) Apixaban 10mg twice daily for 7 days
- D) D) Unfractionated heparin infusion
Show rationale
LMWH (enoxaparin) is first-line for catheter-associated thrombosis per CHEST guidelines, especially with recent surgery. Warfarin (B) requires bridging and monitoring unsuitable for acute management. Apixaban loading (C) isn't standard for provoked thrombosis. Heparin drip (D) requires hospitalization versus LMWH's outpatient feasibility. COPD isn't a direct contraindication for LMWH.
Question 2
A nurse discovers a chemotherapy spill in an outpatient infusion suite where two immunocompromised patients await treatment. The spill kit contains absorbent pads, cytotoxic waste bags, and PPE. Which sequence prioritizes environmental safety?
- A) A) Don PPE → confine spill → dispose of contaminated materials → ventilate area✓
- B) B) Evacuate patients → alert hazardous materials team → post warning signs → decontaminate
- C) C) Apply absorbent material → double-bag waste → wipe with detergent → document exposure
- D) D) Restrict access → put on respirator → neutralize spill → arrange air quality testing
Show rationale
OSHA's hazardous drug handling standards mandate immediate PPE use to protect staff before spill containment. Confining the spill prevents dispersion to adjacent areas where immunocompromised patients are present. Distractors fail this sequencing: B delays containment, C omits initial evacuation/PPE, D uses unnecessary respirators for liquid spills. Oncology Nursing Society protocols emphasize rapid source control to limit airborne particulates in shared spaces.
Question 3
A construction worker taking apixaban for atrial fibrillation misses doses after work-hour reductions. They state, "I skip pills to make the bottle last until payday." Which nurse action aligns with adherence best practices?
- A) A) Contact the provider to discuss transitioning to warfarin with INR monitoring.
- B) B) Provide a pill organizer to improve daily medication tracking.
- C) C) Explore 340B pharmacy programs offering discounted anticoagulants.✓
- D) D) Advise taking half-doses to maintain therapeutic coverage.
Show rationale
Income volatility requires sustainable cost solutions. Option C leverages safety-net pricing for consistent access. Option A introduces monitoring costs and dietary restrictions. Option B doesn't address affordability. Option D risks thrombosis or bleeding. Per CMSRN protocols, nurses should exhaust reduced-cost pharmacy options before changing anticoagulants, as adherence gaps in AFib increase stroke risk fivefold.
Question 4
A newly published RCT shows ginger reduces chemotherapy nausea better than ondansetron in outpatient oncology. A med-surg nurse considers applying this to post-op patients with limited opioid tolerance. What critical appraisal step is most urgent?
- A) A) Verify the RCT’s statistical significance and sample size adequacy
- B) B) Assess whether post-op nausea mechanisms match chemotherapy-induced nausea✓
- C) C) Compare ginger’s cost to ondansetron for budget impact analysis
- D) D) Review institutional policies regarding herbal supplement administration
Show rationale
Applicability appraisal is essential before transferring evidence. While statistical rigor (A) matters, mechanistic differences (chemotherapy vs. post-op cues) may limit relevance. Cost (C) and policies (D) are secondary to clinical appropriateness. Evaluating pathophysiology alignment (B) ensures evidence fits the new context per EBP principles.
Question 5
A 65-year-old on warfarin (INR 2.1) for atrial fibrillation reports headache and blurred vision. BP is 190/110 mmHg, and non-contrast head CT shows no bleed. Neurological exam reveals left homonymous hemianopsia. Which clinical finding necessitates immediate escalation of care?
- A) A) Persistently elevated systolic blood pressure
- B) B) New visual field deficit on confrontation testing✓
- C) C) Therapeutic INR with warfarin therapy
- D) D) Negative head CT with neurological symptoms
Show rationale
Homonymous hemianopsia suggests posterior cerebral artery stroke, requiring urgent intervention despite normal CT (D). AHA guidelines mandate rapid assessment for thrombectomy eligibility within 24 hours. Hypertension (A) may be compensatory and requires controlled reduction to avoid perfusion drop. Therapeutic INR (C) doesn’t preclude ischemic stroke. The visual deficit (B) indicates evolving cortical ischemia, prioritizing neurological evaluation over blood pressure or anticoagulation status alone.
Question 6
A newly admitted patient with aphasia post-stroke has documented allergies to sulfa and latex. During accreditation preparation, the nurse finds the allergy band missing. Which intervention prioritizes both patient safety and accreditation readiness?
- A) A) Notify the provider to rewrite the allergy order before replacing the band
- B) B) Apply a new allergy band immediately after verifying allergies in the EHR✓
- C) C) Document the absence in the chart and report it during shift handoff
- D) D) Place a temporary paper alert at the bedside until pharmacy delivers a band
Show rationale
Accreditation standards require immediate allergy identification. Delaying for provider notification (A) or temporary paper alerts (D) creates safety gaps. Documentation alone (C) doesn't provide real-time visibility. Verifying via EHR ensures accuracy before band replacement. The aphasia increases reliance on visual alerts, making prompt band application critical for preventing allergic reactions during care transitions.
Question 7
A patient with left-sided weakness after stroke attempts to self-transfer using furniture. They have moderate receptive aphasia but can follow visual cues. Which intervention best promotes safe mobility?
- A) A) Provide verbal reminders every two hours to call for assistance with mobility
- B) B) Place a walker with a built-up left handle and demonstrate transfer techniques✓
- C) C) Keep the bed in high position and use pictorial signs showing prohibited actions
- D) D) Apply a seatbelt alarm on the wheelchair and restrict out-of-bed activities
Show rationale
Adaptive walkers compensate for unilateral weakness. Visual demonstration overcomes aphasia barriers and promotes independence. Option A's verbal reminders may not be understood due to receptive aphasia. Option C's high bed position increases fall severity and prohibitive signs don't teach alternatives. Option D's activity restriction promotes deconditioning. CMSRN protocols emphasize tailored assistive devices and visual education for stroke patients to reduce reliance on unsafe strategies.
Question 8
A 55-year-old aphasic stroke patient becomes agitated when the nurse asks about bowel movements. The patient points to a communication board but slams it down after 30 seconds. Vital signs are stable, and the spouse reports this is typical frustration behavior. What should the nurse do next?
- A) A) Delay assessment to allow patient time to regain composure.
- B) B) Ask the spouse to interpret the patient's needs immediately.
- C) C) Use picture cards for yes/no questions about discomfort.✓
- D) D) Document agitation and notify the provider for sedation.
Show rationale
Simple yes/no questions reduce cognitive load for aphasic patients. Option A avoids necessary assessment. Option B violates autonomy by relying on spouse interpretation. Option D medicalizes normal frustration. Cues (typical behavior, stable vitals) indicate adapting communication tools aligns with AMSN's patient-centered approach.
Question 9
Post-stroke patients with aphasia participate in music therapy. Which intervention best supports communication goals?
- A) A) Rhythmic speech training using familiar melodies✓
- B) B) Passive listening to instrumental concertos
- C) C) Songwriting sessions with lyric composition
- D) D) Background nature sounds during meals
Show rationale
Melodic intonation therapy leverages preserved musical processing to improve expressive aphasia, aligning with stroke rehabilitation standards. Passive listening (B) lacks active engagement. Songwriting (C) may frustrate with language demands. Background sounds (D) don't target communication. Familiar melodies enhance neural pathway activation critical for aphasia recovery.
Question 10
A patient with aphasia post-stroke is transferred from rehab with a discharge summary noting "independent with feedings." The nursing aide observes choking during lunch, and the daughter states, "He always needs thick liquids." How should the nurse reconcile feeding ability?
- A) A) Request a speech-language pathology consult for objective assessment✓
- B) B) Follow the discharge summary to prevent conflicting care orders
- C) C) Document the daughter's observation as family-centered input
- D) D) Adjust diet based solely on the nursing aide's clinical observation
Show rationale
A formal swallow evaluation resolves discrepancies between documented function and observed/charted difficulties, per dysphagia management guidelines. Option B ignores acute changes post-discharge. Option C uses unverified family input for clinical decisions. Option D bypasses required diagnostic validation. For patients with communication barriers, objective testing trumps conflicting historical reports when safety risks exist.
Question 11
An 80-year-old with dysphagia post-stroke coughs weakly during oral care. The nurse notes wet vocal quality. Which diagnostic assessment should be prioritized before resuming oral intake?
- A) A) Bedside swallow screening with water test✓
- B) B) Daily weight measurement for hydration status
- C) C) Comprehensive nutritional panel for albumin levels
- D) D) Speech-language pathologist's fiberoptic evaluation
Show rationale
Weak cough and wet voice suggest aspiration risk; bedside screening immediately evaluates swallow safety per AMSN protocols. Weight (B) assesses nutrition but not aspiration. Albumin (C) reflects protein status but doesn't diagnose dysphagia. Fiberoptic evaluation (D) is definitive but requires specialist referral; screening must precede it. The cues (dysphagia, weak cough) mandate rapid bedside assessment to prevent aspiration pneumonia.
Question 12
During EHR downtime, a nurse assesses a post-op patient with new confusion. Which paper documentation element is essential?
- A) A) Subjective descriptions without standardized scales to save time
- B) B) Pre-printed neurological checklist with Glasgow Coma Scale scoring✓
- C) C) Hand-drawn diagrams of pupil reactions on notebook paper
- D) D) Abbreviated notes deferred until EHR reactivation
Show rationale
Structured tools with validated scales (e.g., GCS) provide objective baselines for acute neurological changes (ANA Documentation Principles). Option A lacks measurable data. Option C is non-standardized. Option D delays critical assessment. New post-op confusion requires trendable metrics to guide interventions like stroke evaluations. Pre-printed forms ensure consistency across shifts during prolonged outages.
Question 13
A non-verbal stroke patient with aphasia in a step-down unit grimaces and guards their shoulder during ROM exercises. The family reports the patient was pain-free at rest earlier. Which action should the nurse take first?
- A) A) Administer PRN acetaminophen immediately
- B) B) Document findings as pain likely in the chart
- C) C) Assess using the Non-Communicative Patient's Pain Assessment Instrument (NOPPAIN)✓
- D) D) Request a neurology consult for neuropathic pain evaluation
Show rationale
NOPPAIN evaluates vocalizations, facial expressions, and movement in non-verbal adults, aligning with grimacing and guarding during activity. Collateral data (pain-free at rest) suggests acute, movement-linked pain needing standardized assessment before intervention. Administering analgesics without assessment risks undertreatment. Documentation alone delays action. Neurology consults are premature without initial pain quantification. NOPPAIN provides objective data for targeted interventions per AMSN protocols.
Question 14
An alcoholic patient with pancreatitis has a generalized seizure. Labs show magnesium 1.0 mg/dL, calcium 7.2 mg/dL, and albumin 2.8 g/dL. Which intervention addresses the primary abnormality?
- A) A) Administer 2 g magnesium sulfate IV over 10 minutes✓
- B) B) Infuse 1 g calcium gluconate IV over 20 minutes
- C) C) Give oral magnesium oxide 400 mg twice daily
- D) D) Correct albumin deficit with 25% albumin IV
Show rationale
Seizure is likely due to severe hypomagnesemia (magnesium-dependent ATPase failure), which also causes refractory hypocalcemia. IV magnesium sulfate (A) directly corrects the primary deficit and facilitates calcium absorption. Calcium alone (B) won't resolve magnesium deficiency. Oral magnesium (C) is inadequate for seizures and poorly absorbed in pancreatitis. Albumin (D) doesn't address electrolyte abnormalities. Cues (alcoholism, pancreatitis, concurrent hypocalcemia) confirm magnesium depletion as the root cause per ASPEN critical care guidelines.
Question 15
When planning transfer to home health for a frail elder with heart failure and newly prescribed warfarin, which social determinant most requires pre-discharge intervention?
- A) A) Patient's limited health literacy regarding anticoagulant risks
- B) B) Lack of transportation to INR monitoring appointments✓
- C) C) Inconsistent caregiver availability for daily medication prompts
- D) D) Low-income status affecting ability to purchase medications
Show rationale
INR monitoring is non-negotiable for safe warfarin management. Transportation barriers directly impede this time-sensitive need. Health literacy (A) and caregiver support (C) can be managed by home health education. Medication costs (D) may be addressed through assistance programs but don't prevent immediate monitoring. AMSN standards emphasize solving logistical barriers to essential follow-up since missed INR checks increase stroke/bleeding risks.
