HESI MED SURGE 2023 ACTUAL EXAM
TEST BANK WITH 250 QUESTIONS AND
ANSWERS WITH RATIONALES
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.
A neurologist prescribes a magnetic resonance imaging (MRI) of the head
STAT for a patient. Which data warrants immediate intervention by the
nurse concerning this diagnostic test?
A) Elevated blood pressure.
B) Allergy to shell fish.
C) Right hip replacement.
D) History of atrial fibrillation. - ANSWER-C) Right hip replacement.
The magnetic field generated by the MRI is so strong that metal-containing
items are strongly attracted to the magnet. Because the hip joint is made of
metal, a lead shield must be used during the procedure. Elevated blood
pressure, an allergy to shell fish, and a history of atrial fibrillation would not
affect the MRI.
A client's daughter is sitting by her mother's bedside who was recently
transferred to the Intermediate Care Unit. She states "I don't understand
what a brain attack is. The healthcare provider told me my mother is in
serious condition and they are going to run several tests. I just don't know
what is going on. What happened to my mother?" What is the best
response by the nurse?
,A) "I am sorry, but according to the Health Insurance Portability and
Accounting Act (HIPAA), I cannot give you any information."
B) "Your mother has had a stroke, and the blood supply to the brain has
been blocked."
C) "How do you feel about what the healthcare provider said?"
D) "I will call the healthcare provider so he/she can talk to you about your
mother's serious condition." - ANSWER-B) "Your mother has had a stroke,
and the blood supply to the brain has been blocked."
Rationale: The nurse can discuss what a diagnosis means. Nancy is
unable to make decisions, so the next of kin, her daughter, Gail, needs
sufficient information to make informed decisions. The nurse has the
knowledge, and the responsibility, to explain Nancy's condition to Gail. The
nurse should give facts first, and then address her feelings after the
information is provided.
What is the normal range for cardiac output? - ANSWER-The normal range
for cardiac output to ensure cerebral blood flow and oxygen delivery is 4 to
8 L/min.
A client was admitted with the diagnosis of a brain attack. Their symptoms
began 24 hours before being admitted. Why would this client not be a
candidate for for thrombolytic therapy? - ANSWER-Thrombolytic therapy is
contraindicated in clients with symptom onset longer than 3 hours prior to
admission. This client had symptoms for 24 hours before being brought to
the medical center
What are plate guards? - ANSWER-Plate guards prevent food from being
pushed off the plate. Using plate guards and other assistive devices will
encourage independence in a client with a self-care deficit.
Which condition is considered a non-modifiable risk factor for a brain
attack?
A) High cholesterol levels.
B) Obesity.
C) History of atrial fibrillation.
D) Advanced age. - ANSWER-D) Advanced age.
, Rationale: People over age 55 are a high-risk group for a brain attack
because the incidence of stroke more than doubles in each successive
decade of life. Non-modifiable means the client cannot do anything to
change the risk factor. All the other options are modifiable risk factors.
A client is experiencing homonymous hemianopsia as the result of a brain
attack. Which nursing intervention would the nurse implement to address
this condition?
A) Turn Nancy every two hours and perform active range of motion
exercises.
B) Place the objects Nancy needs for activities of daily living on the left side
of the table.
C) Speak slowly and clearly to assist Nancy in forming sounds to words.
D) Request that the dietary department thicken all liquids on Nancy's meal
and snack trays. - ANSWER-B) Place the objects Nancy needs for
activities of daily living on the left side of the table.
Rationale: Homonymous hemianopsia is loss of the visual field on the
same side as the paralyzed side. This results in the client neglecting that
side of the body, so it is beneficial to place objects on that side. Nancy had
a left-hemisphere brain attack so her right side is the weak side. Speaking
slowly and clearly would address the client's verbal deficits due to aphasia.
Requesting all liquids to be thickened would address dysphagia. Turning
the client every 2 hours and performing active range of motion exercises
would address the client's risk for immobility due to paralysis.
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
TEST BANK WITH 250 QUESTIONS AND
ANSWERS WITH RATIONALES
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.
A neurologist prescribes a magnetic resonance imaging (MRI) of the head
STAT for a patient. Which data warrants immediate intervention by the
nurse concerning this diagnostic test?
A) Elevated blood pressure.
B) Allergy to shell fish.
C) Right hip replacement.
D) History of atrial fibrillation. - ANSWER-C) Right hip replacement.
The magnetic field generated by the MRI is so strong that metal-containing
items are strongly attracted to the magnet. Because the hip joint is made of
metal, a lead shield must be used during the procedure. Elevated blood
pressure, an allergy to shell fish, and a history of atrial fibrillation would not
affect the MRI.
A client's daughter is sitting by her mother's bedside who was recently
transferred to the Intermediate Care Unit. She states "I don't understand
what a brain attack is. The healthcare provider told me my mother is in
serious condition and they are going to run several tests. I just don't know
what is going on. What happened to my mother?" What is the best
response by the nurse?
,A) "I am sorry, but according to the Health Insurance Portability and
Accounting Act (HIPAA), I cannot give you any information."
B) "Your mother has had a stroke, and the blood supply to the brain has
been blocked."
C) "How do you feel about what the healthcare provider said?"
D) "I will call the healthcare provider so he/she can talk to you about your
mother's serious condition." - ANSWER-B) "Your mother has had a stroke,
and the blood supply to the brain has been blocked."
Rationale: The nurse can discuss what a diagnosis means. Nancy is
unable to make decisions, so the next of kin, her daughter, Gail, needs
sufficient information to make informed decisions. The nurse has the
knowledge, and the responsibility, to explain Nancy's condition to Gail. The
nurse should give facts first, and then address her feelings after the
information is provided.
What is the normal range for cardiac output? - ANSWER-The normal range
for cardiac output to ensure cerebral blood flow and oxygen delivery is 4 to
8 L/min.
A client was admitted with the diagnosis of a brain attack. Their symptoms
began 24 hours before being admitted. Why would this client not be a
candidate for for thrombolytic therapy? - ANSWER-Thrombolytic therapy is
contraindicated in clients with symptom onset longer than 3 hours prior to
admission. This client had symptoms for 24 hours before being brought to
the medical center
What are plate guards? - ANSWER-Plate guards prevent food from being
pushed off the plate. Using plate guards and other assistive devices will
encourage independence in a client with a self-care deficit.
Which condition is considered a non-modifiable risk factor for a brain
attack?
A) High cholesterol levels.
B) Obesity.
C) History of atrial fibrillation.
D) Advanced age. - ANSWER-D) Advanced age.
, Rationale: People over age 55 are a high-risk group for a brain attack
because the incidence of stroke more than doubles in each successive
decade of life. Non-modifiable means the client cannot do anything to
change the risk factor. All the other options are modifiable risk factors.
A client is experiencing homonymous hemianopsia as the result of a brain
attack. Which nursing intervention would the nurse implement to address
this condition?
A) Turn Nancy every two hours and perform active range of motion
exercises.
B) Place the objects Nancy needs for activities of daily living on the left side
of the table.
C) Speak slowly and clearly to assist Nancy in forming sounds to words.
D) Request that the dietary department thicken all liquids on Nancy's meal
and snack trays. - ANSWER-B) Place the objects Nancy needs for
activities of daily living on the left side of the table.
Rationale: Homonymous hemianopsia is loss of the visual field on the
same side as the paralyzed side. This results in the client neglecting that
side of the body, so it is beneficial to place objects on that side. Nancy had
a left-hemisphere brain attack so her right side is the weak side. Speaking
slowly and clearly would address the client's verbal deficits due to aphasia.
Requesting all liquids to be thickened would address dysphagia. Turning
the client every 2 hours and performing active range of motion exercises
would address the client's risk for immobility due to paralysis.
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
