HESI RN MEDICAL SURGICAL EXAM PACK 2024
QUESTIONS AND ANSWERS
1. 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. A hyperreflexic deep tendon relexes.
D. Decreased bowel sounds:
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.
2. 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.
1/107
, HESI RN MEDICAL SURGICAL EXAM PACK 2024
QUESTIONS AND ANSWERS
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.
3. 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.
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. 4. 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?
, HESI RN MEDICAL SURGICAL EXAM PACK 2024
QUESTIONS AND ANSWERS
A) Elevated
blood pressure.
B) Allergy to
shell fish.
C) Right hip
replacement.
D) History of atrial fibrillation.
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.
5. 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?"
3/107
, HESI RN MEDICAL SURGICAL EXAM PACK 2024
QUESTIONS AND ANSWERS
D) "I will call the healthcare provider so he/she can talk to you
about your mother's serious condition.":
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.
6. What is the normal range for cardiac output?: The normal range
for cardiac output to ensure cerebral blood flow and oxygen delivery
is 4 to 8 L/min.
7. 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?: 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
8. What are plate guards? : 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.
9. Which condition is considered a non-modifiable risk factor
for a brain attack?
A) High cholesterol levels.
B) Obesity.
C) History of atrial fibrillation.
QUESTIONS AND ANSWERS
1. 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. A hyperreflexic deep tendon relexes.
D. Decreased bowel sounds:
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.
2. 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.
1/107
, HESI RN MEDICAL SURGICAL EXAM PACK 2024
QUESTIONS AND ANSWERS
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.
3. 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.
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. 4. 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?
, HESI RN MEDICAL SURGICAL EXAM PACK 2024
QUESTIONS AND ANSWERS
A) Elevated
blood pressure.
B) Allergy to
shell fish.
C) Right hip
replacement.
D) History of atrial fibrillation.
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.
5. 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?"
3/107
, HESI RN MEDICAL SURGICAL EXAM PACK 2024
QUESTIONS AND ANSWERS
D) "I will call the healthcare provider so he/she can talk to you
about your mother's serious condition.":
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.
6. What is the normal range for cardiac output?: The normal range
for cardiac output to ensure cerebral blood flow and oxygen delivery
is 4 to 8 L/min.
7. 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?: 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
8. What are plate guards? : 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.
9. Which condition is considered a non-modifiable risk factor
for a brain attack?
A) High cholesterol levels.
B) Obesity.
C) History of atrial fibrillation.
