Med surg – hesi Questions with Correct
Answers & Detailed Answers | Full Coverage of
All Competencies | 2026 Latest Version Graded
A+
A physical therapist (PT) places a gait belt on a client and is
assisting them with ambulation from the bed to the chair. As
they get up out of the bed, they report being dizzy and begin to
fall. The PT carefully allows them to fall back to the bed and
notifies the primary nurse. Which written documentation
should the nurse put in the client's record?
A) Client experienced orthostatic hypotension when getting out
of bed.
B) PT reported client complained of dizziness when getting out
of bed, and gait belt was used to allow client to fall back onto
the bed.
C) PT notified the primary nurse that the client could not
ambulate at this time because of dizziness.
,D) Client had difficulty ambulating from the bed to the chair
when accompanied by the PT, variance report completed. -
✔✔ANSWER ✔✔-B) PT reported client complained of dizziness
when getting out of bed, and gait belt was used to allow client
to fall back onto the bed.
Rationale: This documentation provides the factual data of the
events that occurred. A)The nurse is making an assumption that
the dizziness was caused by orthostatic hypotension. C) Not all
the pertinent facts are included in this documentation.
D) A variance report should never be documented in the client's
record.
An ER nurse is completing an assessment on a patient that is
alert but struggles to answer questions. When she attempts to
talk, she slurs her speech and appears very frightened. What
additional clinical manifestation does the nurse expect to find if
nacy's sysmptoms have been caused by a brain attack (stroke)?
A. A carotid bruit
B. A hypotensive blood pressure
C. hyperreflexic deep tendon relexes.
,D. Decreased bowel sounds - ✔✔ANSWER ✔✔-A) A carotid
bruit.
Rationale: the carotid artery (artery to the brain) is narrowed in
clients with a brain attack. A bruit is an abnormal sound heard
on auscultation resulting from interference with normal blood
flow. Usually the blood pressure is hypertensive. Initially flaccid
paralysis occurs, resulting in hyporefkexic deep tendon reflexes.
Bowel sounds are not indicative of a brain attack.
Which clinical manifestation further supports an assessment of
a left-sided brain attack?
A) Visual field deficit on the left side.
B) Spatial-perceptual deficits.
C) Paresthesia of the left side.
D) Global aphasia.
D) Global aphasia. - ✔✔ANSWER ✔✔-D) Global aphasia.
Rationale: Global aphasia refers to difficulty speaking, listening,
and understanding, as well as difficulty reading and writing.
Symptoms vary from person to person. Aphasia may occur
secondary to any brain injury involving the left hemisphere.
, Visual field deficits, spatial-perceptual deficits, and paresthsia
of the left side usually occur with right-sided brain attack.
When preparing a patient for a noncontrast computed
tomography (CT) scan STAT, what nursing intervention should
the nurse implement?
A) Determine if the client has any allergies to iodine
B) Explain that the client will not be able to move her head
throughout the CT scan.
C) Premedicate the client to decrease pain prior to having the
procedure.
D) Provide an explanation of relaxation exercises prior to the
procedure. - ✔✔ANSWER ✔✔-B) Explain that the client will not
be able to move her head throughout the CT scan.
Rationale: Because head motion will distort the images, Nancy
will have to remain still throughout the procedure. Allergies to
iodine is important if contrast dye is being used for the CT scan.
Premedicating the client to decrease pain prior to the
procedure is unnecessary because CT scanning is a noninvasive
and painless procedure. Providing an explanation of relaxation
exercises prior to the procedure is a worthwhile intervention to
decrease anxiety but is not of highest priority.
Answers & Detailed Answers | Full Coverage of
All Competencies | 2026 Latest Version Graded
A+
A physical therapist (PT) places a gait belt on a client and is
assisting them with ambulation from the bed to the chair. As
they get up out of the bed, they report being dizzy and begin to
fall. The PT carefully allows them to fall back to the bed and
notifies the primary nurse. Which written documentation
should the nurse put in the client's record?
A) Client experienced orthostatic hypotension when getting out
of bed.
B) PT reported client complained of dizziness when getting out
of bed, and gait belt was used to allow client to fall back onto
the bed.
C) PT notified the primary nurse that the client could not
ambulate at this time because of dizziness.
,D) Client had difficulty ambulating from the bed to the chair
when accompanied by the PT, variance report completed. -
✔✔ANSWER ✔✔-B) PT reported client complained of dizziness
when getting out of bed, and gait belt was used to allow client
to fall back onto the bed.
Rationale: This documentation provides the factual data of the
events that occurred. A)The nurse is making an assumption that
the dizziness was caused by orthostatic hypotension. C) Not all
the pertinent facts are included in this documentation.
D) A variance report should never be documented in the client's
record.
An ER nurse is completing an assessment on a patient that is
alert but struggles to answer questions. When she attempts to
talk, she slurs her speech and appears very frightened. What
additional clinical manifestation does the nurse expect to find if
nacy's sysmptoms have been caused by a brain attack (stroke)?
A. A carotid bruit
B. A hypotensive blood pressure
C. hyperreflexic deep tendon relexes.
,D. Decreased bowel sounds - ✔✔ANSWER ✔✔-A) A carotid
bruit.
Rationale: the carotid artery (artery to the brain) is narrowed in
clients with a brain attack. A bruit is an abnormal sound heard
on auscultation resulting from interference with normal blood
flow. Usually the blood pressure is hypertensive. Initially flaccid
paralysis occurs, resulting in hyporefkexic deep tendon reflexes.
Bowel sounds are not indicative of a brain attack.
Which clinical manifestation further supports an assessment of
a left-sided brain attack?
A) Visual field deficit on the left side.
B) Spatial-perceptual deficits.
C) Paresthesia of the left side.
D) Global aphasia.
D) Global aphasia. - ✔✔ANSWER ✔✔-D) Global aphasia.
Rationale: Global aphasia refers to difficulty speaking, listening,
and understanding, as well as difficulty reading and writing.
Symptoms vary from person to person. Aphasia may occur
secondary to any brain injury involving the left hemisphere.
, Visual field deficits, spatial-perceptual deficits, and paresthsia
of the left side usually occur with right-sided brain attack.
When preparing a patient for a noncontrast computed
tomography (CT) scan STAT, what nursing intervention should
the nurse implement?
A) Determine if the client has any allergies to iodine
B) Explain that the client will not be able to move her head
throughout the CT scan.
C) Premedicate the client to decrease pain prior to having the
procedure.
D) Provide an explanation of relaxation exercises prior to the
procedure. - ✔✔ANSWER ✔✔-B) Explain that the client will not
be able to move her head throughout the CT scan.
Rationale: Because head motion will distort the images, Nancy
will have to remain still throughout the procedure. Allergies to
iodine is important if contrast dye is being used for the CT scan.
Premedicating the client to decrease pain prior to the
procedure is unnecessary because CT scanning is a noninvasive
and painless procedure. Providing an explanation of relaxation
exercises prior to the procedure is a worthwhile intervention to
decrease anxiety but is not of highest priority.
