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Obese 45-year-old Native American. While obesity is a significant risk factor for cardiovascular disease and stroke, this patient is younger and does not have a higher-risk comorbidity like hypertension. Although Native Americans do experience higher rates of diabetes and obesity, these factors alone do not surpass the combined risks of age, race, and hypertension in the correct choice.

35-year-old Asian American woman who smokes. Smoking increases clot formation and accelerates atherosclerosis, raising stroke risk. However, this patient is relatively young, and her overall risk remains lower compared to an older hypertensive African American man. The protective factor of younger age offsets her smoking risk.

32-year-old white woman taking oral contraceptives. Oral contraceptives slightly increase the risk of thrombotic stroke, especially in women who also smoke or have migraines with aura. Still, this patient is the youngest in the group and lacks additional high-risk conditions like hypertension or advanced age.

Amount of cardiac output. While overall cardiac output affects systemic blood flow, the brain has autoregulatory mechanisms that maintain relatively constant perfusion unless there is severe heart failure or shock. Stroke severity is not primarily determined by cardiac output but by localized cerebral circulation.

Oxygen content of the blood. Low oxygen levels, such as in severe anemia or hypoxemia, can worsen brain injury but are not the primary factor in determining stroke damage. Most stroke patients have normal oxygenation, and localized blood supply plays a bigger role in infarct size.

Level of carbon dioxide in the blood. Carbon dioxide levels do influence cerebral blood flow through vasodilation and vasoconstriction, but this effect is transient. It does not determine the extent of permanent stroke damage as much as collateral circulation does.

Sensory disturbance. Sensory changes such as numbness, tingling, or altered sensation can occur in both thrombotic and hemorrhagic strokes. They do not help distinguish between the two types, since both involve interruption of neural pathways.

A history of hypertension. Although hypertension is a major risk factor for hemorrhagic stroke, it is also the most significant risk factor for ischemic strokes. Therefore, its presence cannot differentiate between thrombotic and hemorrhagic events.

Presence of motor weakness. Motor weakness, such as hemiparesis, is a common symptom in both types of stroke. It results from decreased blood supply or damage to motor areas of the brain, so it does not specifically indicate hemorrhage.

Limiting fluid intake. Restricting fluids can lead to dehydration, urinary tract infections, and concentrated urine, which worsens bladder irritation. Adequate hydration is essential for urinary health and overall stroke recovery, making fluid restriction inappropriate for bladder training.

Keeping a urinal in place at all times. While convenient, leaving a urinal in place encourages dependence and does not retrain the bladder. The goal is to help the patient regain normal voiding habits rather than rely on a permanent external device.

Catheterizing the patient every 4 hours. Intermittent catheterization may be needed in cases of urinary retention, but routine catheterization increases the risk of infection and does not support retraining. It should not be used as a standard method for managing post-stroke incontinence.

Presence of increased ICP. Increased intracranial pressure is diagnosed clinically and with imaging such as CT or MRI, not with angiography. Angiography does not measure intracranial pressure levels.

Site and size of the infarction. The site and extent of brain tissue damage are better identified using CT or MRI scans, which show actual infarcted or hemorrhagic areas. Angiography only shows blood flow, not tissue damage.

Presence of blood in the cerebrospinal fluid. This is assessed by a lumbar puncture, which directly samples CSF, not by angiography. Angiography is not used to diagnose subarachnoid hemorrhage through CSF analysis.

Decrease cerebral edema. Carotid endarterectomy does not treat cerebral swelling. Cerebral edema is managed medically with osmotic diuretics, corticosteroids (in some cases), or surgical decompression, not with vascular surgery.

Reduce the brain damage that occurs during a stroke in evolution. Once a stroke is actively occurring, endarterectomy is not indicated because it cannot reverse acute ischemic brain damage. It is a preventive, not acute, intervention.

Provide a circulatory bypass around thrombotic plaques obstructing cranial circulation. Carotid endarterectomy does not involve bypassing blocked arteries; instead, it involves direct removal of the obstruction (plaque) from the carotid artery.

Furosemide (Lasix). This is a loop diuretic used to manage fluid overload in conditions like heart failure or renal disease. It has no role in preventing thrombus formation or reducing stroke incidence in TIA patients.

Lovastatin (Mevacor). Statins help reduce cholesterol and are useful in long-term prevention of atherosclerotic disease. However, their role is more in reducing cardiovascular risk over time rather than immediate prevention of stroke following TIAs.

Nimodipine (Nimotop). This calcium channel blocker is specifically used to prevent cerebral vasospasm after subarachnoid hemorrhage, not in the prevention of ischemic stroke after TIAs.

Intravenous fluid replacement. Although fluids may be required for hemodynamic stability, aggressive replacement is not the first priority. Overhydration can worsen cerebral edema, and fluids should be carefully balanced after airway and breathing are stabilized.

Administration of osmotic diuretics to reduce cerebral edema. Osmotic diuretics like mannitol are sometimes used in the management of increased intracranial pressure, but this is not the first-line emergency intervention. Their use comes later, guided by imaging and clinical findings, not before airway stabilization.

Initiation of hypothermia to decrease the oxygen needs of the brain. Therapeutic hypothermia is not a standard initial treatment for stroke in the emergency setting. It may be explored in research or specialized contexts, but it does not replace basic airway and oxygen management.

Order a soft diet for the patient. Ordering food before assessing the patient’s gag reflex or swallow ability is unsafe. If the patient aspirates, it may lead to pneumonia or airway obstruction, which worsens outcomes after a stroke.

Raise the head of the bed to a sitting position. While this position is helpful in reducing aspiration risk and aiding breathing, it should not be the very first action. Without confirming the gag reflex, even upright positioning cannot fully protect against aspiration during oral intake.

Evaluate the patient’s ability to swallow small amounts of crushed ice or ice water. Swallow trials should never be attempted before confirming a gag reflex. Testing swallowing too early may directly expose the patient to aspiration risks.

Fruit juices. Thin liquids like juice are among the most difficult to swallow for patients with dysphagia. They move too quickly through the oropharynx, increasing the risk of aspiration. Thickened liquids are preferred instead.

Pureed meat. While pureed foods are appropriate for moderate to severe dysphagia, they are unnecessarily restrictive for mild dysphagia. They may also be unappealing, leading to poor oral intake and reduced nutrition.

Fortified milkshakes. Like fruit juices, milkshakes are thin liquids unless thickened. These can increase aspiration risk in patients with impaired swallowing function. Even though they are nutrient-rich, they are unsafe without consistency modification.

“He didn’t arrive within the timeframe for that therapy.” While time is critical for ischemic strokes, the main issue here is that the patient has a hemorrhagic stroke. This answer would be misleading and fail to address the real reason tPA was not given.

“Not everyone is eligible for this drug. Has he had surgery lately?” This is true for ischemic stroke patients, as recent surgery or bleeding risk may exclude them. However, it is not relevant in this case because the stroke is hemorrhagic, making tPA absolutely contraindicated.

“You should discuss the treatment of your husband with his doctor.” Although involving the doctor is appropriate, this answer avoids the nurse’s responsibility to provide accurate teaching. It may leave the wife feeling dismissed or more anxious.

Use gestures, pictures, and music to stimulate patient responses. Gestures, pictures, and simple statements are more appropriate in the acute phase,

Structure statements so that the patient does not have to respond verbally. Avoiding verbal responses limits opportunities for the patient to practice and regain language skills. Rehabilitation aims to encourage active communication.

Use flashcards with simple words and pictures to promote recall of language. Flashcards are often perceived by the patient as childish and meaningless. Not responding verbally does not promote communication.

Avoid positioning the patient on the affected side. Avoidance reinforces neglect and increases the risk of pressure injuries and contractures by not using or monitoring the affected side.

Place all objects for care on the patient’s unaffected side. While convenient, this worsens neglect by limiting opportunities to interact with the affected side. Rehabilitation requires stimulation of the neglected field.

Protect the affected side from injury with pillows and supports. Positioning aids are useful but insufficient as the primary intervention. Without retraining awareness, the patient remains at high risk for long-term neglect and dependency.