MATERNITY/OB PN HESI SPECIALTY V2
1. A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily.
When the nurse is administering medications, the patient says, “I don’t need the aspirin today. I don’t
have a fever.” Which action should the nurse take?
a. Document that the aspirin was refused by the patient.
b. Tell the patient that the aspirin is used to prevent a fever.
c. Explain that the aspirin is ordered to decrease stroke risk.
d. Call the health care provider to clarify the medication
order. ANS: C
Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the
patient’s refusal to take the medication is an inadequate response by the nurse. There is no need to clarify
the order with the health care provider. The aspirin is not ordered to prevent aches and pains.
2. A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved
after 2 hours. The nurse will anticipate teaching the patient about
a. tPA. c. warfarin (Coumadin).
b. aspirin . d.
nimodipine ANS: B
After a transient ischemic attack, patients typically are started on medications such as aspirin to inhibit
platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used
for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid
hemorrhage.
3. A patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should
a. use a calm voice to ask the patient to stop the crying behavior.
b. explain to the family that depression is normal following a stroke.
c. have the family members leave the patient alone for a few minutes.
d. teach the family that emotional outbursts are common after
strokes. ANS: D
Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to
the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient’s
outburst suggests that depression is not the major cause of the behavior. The family should stay with the
patient. The crying is not within the patient’s control, and asking the patient to stop will lead to
embarrassment.
4. Which stroke risk factor for a 48-yr-old male patient in the clinic is most important for the nurse
to address?
a. The patient is 25 lb above the ideal weight.
b. The patient drinks a glass of red wine with dinner daily.
c. The patient’s usual blood pressure (BP) is 170/94 mm Hg.
d. The patient works at a desk and relaxes by watching
television. ANS: C
Hypertension is the single most important modifiable risk factor. People who drink more than 1 (for women)
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, or 2 (for men) alcoholic beverages a day may increase their risk for hypertension. Physical inactivity and
obesity contribute to stroke risk but not as much as hypertension.
5. A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an
intracerebral hemorrhage. Which information about the patient is most important to communicate to
the health care provider?
a. The patient’s speech is difficult to understand.
b. The patient’s blood pressure (BP) is 144/90 mm Hg.
c. The patient takes a diuretic because of a history of hypertension.
d. The patient has atrial fibrillation and takes warfarin
(Coumadin). ANS: D
The use of warfarin probably contributed to the intracerebral bleeding and remains a risk factor for further
bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the
patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient
but has no immediate effect on the patient’s care. The BP of 144/90 indicates the need for ongoing
monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided
stroke, and no change in therapy is indicated.
6. A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department
and diagnostic tests are ordered. Which test should be done first?
a. Complete blood count (CBC)
b. Chest radiograph (chest x-ray)
c. Computed tomography (CT) scan d. 12-Lead
electrocardiogram (ECG) ANS: C
Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen
activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke.
The sooner the tPA is given, the less brain injury. The other diagnostic tests give information about possible
causes of the stroke and do not need to be completed as urgently as the CT scan.
7. Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively
increasing weakness and decreasing level of consciousness. Which patient problem do they determine
has the highest priority for the patient?
a. Impaired physical mobility related to weakness
b. Disturbed sensory perception related to brain injury
c. Risk for impaired skin integrity related to immobility
d. Risk for aspiration related to inability to protect airway
ANS: D
Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other
diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time.
ALL HESI LINKS AVAILABLE
HESI PN COMPREHENSIVE EXIT EXAM (14 VERSIONS) (NEWEST - 2021) |
COMPLETE DOCUMENTS | 100 % CORRECT
https://www.stuvia.com/doc/1116973/hesi-pn-comprehensive-exit-exam-14-versions-newest-2021-
complete-documents-100-correct
2
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1. A patient who has a history of a transient ischemic attack (TIA) has an order for aspirin 160 mg daily.
When the nurse is administering medications, the patient says, “I don’t need the aspirin today. I don’t
have a fever.” Which action should the nurse take?
a. Document that the aspirin was refused by the patient.
b. Tell the patient that the aspirin is used to prevent a fever.
c. Explain that the aspirin is ordered to decrease stroke risk.
d. Call the health care provider to clarify the medication
order. ANS: C
Aspirin is ordered to prevent stroke in patients who have experienced TIAs. Documentation of the
patient’s refusal to take the medication is an inadequate response by the nurse. There is no need to clarify
the order with the health care provider. The aspirin is not ordered to prevent aches and pains.
2. A patient in the clinic reports a recent episode of dysphasia and left-sided weakness at home that resolved
after 2 hours. The nurse will anticipate teaching the patient about
a. tPA. c. warfarin (Coumadin).
b. aspirin . d.
nimodipine ANS: B
After a transient ischemic attack, patients typically are started on medications such as aspirin to inhibit
platelet function and decrease stroke risk. tPA is used for acute ischemic stroke. Coumadin is usually used
for patients with atrial fibrillation. Nimodipine is used to prevent cerebral vasospasm after a subarachnoid
hemorrhage.
3. A patient with a left-brain stroke suddenly bursts into tears when family members visit. The nurse should
a. use a calm voice to ask the patient to stop the crying behavior.
b. explain to the family that depression is normal following a stroke.
c. have the family members leave the patient alone for a few minutes.
d. teach the family that emotional outbursts are common after
strokes. ANS: D
Patients who have left-sided brain stroke are prone to emotional outbursts that are not necessarily related to
the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient’s
outburst suggests that depression is not the major cause of the behavior. The family should stay with the
patient. The crying is not within the patient’s control, and asking the patient to stop will lead to
embarrassment.
4. Which stroke risk factor for a 48-yr-old male patient in the clinic is most important for the nurse
to address?
a. The patient is 25 lb above the ideal weight.
b. The patient drinks a glass of red wine with dinner daily.
c. The patient’s usual blood pressure (BP) is 170/94 mm Hg.
d. The patient works at a desk and relaxes by watching
television. ANS: C
Hypertension is the single most important modifiable risk factor. People who drink more than 1 (for women)
1
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https://www.coursehero.com/file/96539375/MATERNITYOB-PN-HESI-SPECIALTY-V2docx/
, or 2 (for men) alcoholic beverages a day may increase their risk for hypertension. Physical inactivity and
obesity contribute to stroke risk but not as much as hypertension.
5. A patient in the emergency department with sudden-onset right-sided weakness is diagnosed with an
intracerebral hemorrhage. Which information about the patient is most important to communicate to
the health care provider?
a. The patient’s speech is difficult to understand.
b. The patient’s blood pressure (BP) is 144/90 mm Hg.
c. The patient takes a diuretic because of a history of hypertension.
d. The patient has atrial fibrillation and takes warfarin
(Coumadin). ANS: D
The use of warfarin probably contributed to the intracerebral bleeding and remains a risk factor for further
bleeding. Administration of vitamin K is needed to reverse the effects of the warfarin, especially if the
patient is to have surgery to correct the bleeding. The history of hypertension is a risk factor for the patient
but has no immediate effect on the patient’s care. The BP of 144/90 indicates the need for ongoing
monitoring but not for any immediate change in therapy. Slurred speech is consistent with a left-sided
stroke, and no change in therapy is indicated.
6. A patient with left-sided weakness that started 60 minutes earlier is admitted to the emergency department
and diagnostic tests are ordered. Which test should be done first?
a. Complete blood count (CBC)
b. Chest radiograph (chest x-ray)
c. Computed tomography (CT) scan d. 12-Lead
electrocardiogram (ECG) ANS: C
Rapid screening with a noncontrast CT scan is needed before administration of tissue plasminogen
activator (tPA), which must be given within 4.5 hours of the onset of clinical manifestations of the stroke.
The sooner the tPA is given, the less brain injury. The other diagnostic tests give information about possible
causes of the stroke and do not need to be completed as urgently as the CT scan.
7. Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively
increasing weakness and decreasing level of consciousness. Which patient problem do they determine
has the highest priority for the patient?
a. Impaired physical mobility related to weakness
b. Disturbed sensory perception related to brain injury
c. Risk for impaired skin integrity related to immobility
d. Risk for aspiration related to inability to protect airway
ANS: D
Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other
diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time.
ALL HESI LINKS AVAILABLE
HESI PN COMPREHENSIVE EXIT EXAM (14 VERSIONS) (NEWEST - 2021) |
COMPLETE DOCUMENTS | 100 % CORRECT
https://www.stuvia.com/doc/1116973/hesi-pn-comprehensive-exit-exam-14-versions-newest-2021-
complete-documents-100-correct
2
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