SCRN Sample Set | Nurse.ICU

1

A patient arrives with last-known-well 90 minutes ago and a suspected acute ischemic stroke. Which action is the priority to expedite treatment?

Correct: B

The first imaging priority in suspected acute stroke is an emergent non-contrast head CT to rule out hemorrhage — thrombolytics cannot be given until bleeding is excluded. Aspirin is withheld until hemorrhage is excluded and (if thrombolytics are given) for 24 hours. Heparin is not indicated acutely, and waiting for MRI wastes the treatment window.

A. Aspirin is withheld until hemorrhage is excluded and is not given within 24 h of thrombolytics.
B. Correct. Non-contrast CT rules out hemorrhage first — the gateway to thrombolysis.
C. MRI is more sensitive but slower; CT is the time-critical first study.
D. Acute anticoagulation is not indicated and increases bleeding risk.

2

Per the 2026 AHA/ASA guideline, what is the recommended dose of tenecteplase for eligible acute ischemic stroke patients within 4.5 hours?

Correct: C

The 2026 AHA/ASA guideline gives tenecteplase 0.25 mg/kg (max 25 mg) as a single IV bolus a Class I recommendation, co-equal with alteplase, for eligible patients within 4.5 hours. The 0.9 mg/kg regimen describes alteplase. The 0.4 mg/kg dose was studied but showed no benefit and more bleeding, so 0.25 mg/kg is preferred.

A. 0.9 mg/kg with a 10% bolus is the alteplase regimen, not tenecteplase.
B. Tenecteplase is a bolus, not a 60-minute infusion.
C. Correct. TNK 0.25 mg/kg (max 25 mg) single bolus — 2026 Class I.
D. 0.4 mg/kg was not superior and carried more bleeding risk.

3

A patient received IV thrombolytics for acute ischemic stroke. What is the target blood pressure to maintain in the first 24 hours after treatment?

Correct: B

After IV thrombolysis, blood pressure must be kept below 180/105 mmHg for at least 24 hours to reduce the risk of symptomatic intracerebral hemorrhage. (Before thrombolysis, the threshold to treat is 185/110.) The 220/120 threshold applies to patients NOT receiving thrombolytics who are permissively managed.

A. Below 160/100 is not the guideline post-thrombolytic threshold.
B. Correct. Post-thrombolytic target is below 180/105 for 24 hours.
C. Below 140/90 is stricter than recommended acutely and risks hypoperfusion.
D. Below 220/120 is the permissive threshold for patients not given thrombolytics.

4

A patient presents with contralateral leg weakness greater than arm weakness. Occlusion of which artery is most consistent with this presentation?

Correct: D

The anterior cerebral artery supplies the medial frontal and parietal lobes, including the leg area of the motor and sensory homunculus. ACA occlusion therefore causes contralateral weakness that is worse in the leg than the arm. MCA strokes affect the face/arm more than the leg; PCA affects vision; basilar affects the brainstem.

A. Basilar occlusion causes brainstem signs (crossed deficits, coma).
B. PCA occlusion causes visual field deficits, not leg-dominant weakness.
C. MCA strokes cause face/arm weakness greater than leg.
D. Correct. The ACA supplies the medial motor cortex — the leg region.

5

A patient is being evaluated for mechanical thrombectomy. Which imaging finding best supports the presence of salvageable brain tissue?

Correct: B

A favorable thrombectomy profile shows a small infarct core with a large penumbra — the "mismatch" between already-dead tissue and hypoperfused-but-salvageable tissue. That mismatch is what thrombectomy aims to rescue and is central to extended-window selection. A completed large infarct, edema with shift, or an old lacune do not indicate salvageable tissue.

A. Edema with midline shift indicates established injury, not a target for reperfusion.
B. Correct. Small core + large penumbra = salvageable tissue (favorable mismatch).
C. A completed large infarct means the tissue is already lost.
D. A chronic lacune is old, non-salvageable tissue.

6

Before a patient with acute stroke may take anything by mouth, which nursing assessment is the priority to prevent aspiration?

Correct: A

A validated bedside swallow screen must be passed before any oral intake — including oral medications — because dysphagia and aspiration are common and dangerous after stroke. This is a core stroke-certification and Joint Commission quality measure. The gag reflex alone does not reliably predict safe swallowing.

A. Correct. A bedside swallow screen before any PO intake prevents aspiration.
B. Bowel sounds do not assess swallowing safety.
C. The gag reflex alone does not reliably predict safe swallowing.
D. Abdominal girth is unrelated to aspiration risk.

7

Which modifiable risk factor has the strongest association with both ischemic and hemorrhagic stroke and is the priority for secondary prevention teaching?

Correct: C

Hypertension is the single most important MODIFIABLE risk factor for both ischemic and hemorrhagic stroke, so blood-pressure control anchors secondary prevention teaching. Family history, age, and sex are non-modifiable and cannot be the focus of behavior-change education.

A. Family history is non-modifiable.
B. Advancing age is non-modifiable.
C. Correct. Hypertension is the leading modifiable stroke risk factor.
D. Sex is non-modifiable.

8

A patient with a left-hemisphere stroke has expressive (Broca) aphasia. Which nursing communication strategy is most appropriate?

Correct: B

In expressive aphasia, comprehension is relatively intact but producing speech is impaired. Yes/no questions plus extra response time let the patient communicate successfully and reduce frustration. Speaking loudly/fast, finishing sentences, or avoiding communication all undermine the patient’s autonomy and dignity.

A. Volume and speed do not help aphasia and add stress.
B. Correct. Yes/no questions with extra time match preserved comprehension.
C. Communication should continue, adapted, not be avoided.
D. Completing sentences removes the patient’s control and can be demeaning.

9

Which time metric is the primary quality benchmark for a patient receiving IV thrombolytics in the emergency department?

Correct: C

Door-to-needle time — arrival to the start of IV thrombolytics — is the core ED stroke quality metric, with a national target of 60 minutes or less (and increasingly 45 or 30). It directly reflects how fast the stroke system delivers reperfusion. The other intervals are tracked but are not the thrombolytic benchmark.

A. Onset-to-arrival is largely outside hospital control and not the treatment metric.
B. Door-to-floor measures admission flow, not thrombolytic timeliness.
C. Correct. Door-to-needle (≤60 min target) is the thrombolytic benchmark.
D. Door-to-discharge reflects length of stay, not acute reperfusion speed.

10

Thirty minutes into an alteplase infusion, a stroke patient develops a severe headache, acute hypertension, nausea, and a declining level of consciousness. What is the nurse’s FIRST action?

Correct: D

Sudden severe headache, acute hypertension, nausea/vomiting, and neurologic decline during thrombolysis signal symptomatic intracerebral hemorrhage until proven otherwise. The nurse must STOP the infusion immediately and activate the provider/stroke team for emergent CT and reversal. Slowing the drip, treating only symptoms, or giving fluids all delay life-saving intervention.

A. Slowing the infusion still delivers thrombolytic during a suspected bleed.
B. Treating nausea alone ignores the emergency and wastes time.
C. Increasing fluids does not address the suspected hemorrhage.
D. Correct. Stop the thrombolytic and escalate — this is likely symptomatic ICH.