HESI 101- MED SURGE HESI RN 2 LATEST
VERSIONS 2024-2025 WITH QUESTIONS AND
CORRECT ANSWERS|A GRADE
The nurse is planning care for a client who has a right hemispheric stroke.
Which nursing diagnosis should the nurse include in the plan of care?
A Impaired physical mobility related to right-sided hemiplegia.
B Risk for injury related to denial of deficits and impulsiveness.
C Impaired verbal communication related to speech-language deficits.
D Ineffective coping related to depression and distress about disability.
B) Risk for injury related to denial of deficits and impulsiveness.
With right-brain damage, a client experience difficulty in judgment and spatial
perception and is more likely to be impulsive and move quickly, which placing the
client at risk for falls (B). Although clients with right and left hemisphere damage
may experience impaired physical mobility, the client with right brain damage will
manifest physical impairments on the contralateral side of the body, not the same
side (A). The client with a left-brain injury may manifest right-sided hemiplegia with
speech or language deficits (C). A client with left-brain damage is more likely to be
aware of the deficits and experience grief related to physical impairment and
depression (D).
After checking the urinary drainage system for kinks in the tubing, the
nurse determines that a client who has returned from the post-anesthesia
care has a dark, concentrated urinary output of 54 ml for the last 2 hours.
What priority nursing action should be implemented?
A Report the findings to the surgeon.
B Irrigate the indwelling urinary catheter.
C Apply manual pressure to the bladder.
D Increase the IV flow rate for 15 minutes.
A) Report the findings to the surgeon.
An adult who weighs 132 pounds (60 kg) should produce about 60 ml of urine
hourly (1 ml/kg/hour). Dark, concentrated, and low volume of urine output should be
reported to the surgeon. Although other actions (B, C, and D) may be indicated, the
assessment findings should be reported to the healthcare provider.
The nurse is assessing a client who has a history of Parkinson's disease for
the past 5 years. What symptoms should this client most likely exhibit?
Loss of short-term memory, facial tics and grimaces, and constant writhing
movements.
Shuffling gait, masklike facial expression, and tremors of the head.
VERSIONS 2024-2025 WITH QUESTIONS AND
CORRECT ANSWERS|A GRADE
The nurse is planning care for a client who has a right hemispheric stroke.
Which nursing diagnosis should the nurse include in the plan of care?
A Impaired physical mobility related to right-sided hemiplegia.
B Risk for injury related to denial of deficits and impulsiveness.
C Impaired verbal communication related to speech-language deficits.
D Ineffective coping related to depression and distress about disability.
B) Risk for injury related to denial of deficits and impulsiveness.
With right-brain damage, a client experience difficulty in judgment and spatial
perception and is more likely to be impulsive and move quickly, which placing the
client at risk for falls (B). Although clients with right and left hemisphere damage
may experience impaired physical mobility, the client with right brain damage will
manifest physical impairments on the contralateral side of the body, not the same
side (A). The client with a left-brain injury may manifest right-sided hemiplegia with
speech or language deficits (C). A client with left-brain damage is more likely to be
aware of the deficits and experience grief related to physical impairment and
depression (D).
After checking the urinary drainage system for kinks in the tubing, the
nurse determines that a client who has returned from the post-anesthesia
care has a dark, concentrated urinary output of 54 ml for the last 2 hours.
What priority nursing action should be implemented?
A Report the findings to the surgeon.
B Irrigate the indwelling urinary catheter.
C Apply manual pressure to the bladder.
D Increase the IV flow rate for 15 minutes.
A) Report the findings to the surgeon.
An adult who weighs 132 pounds (60 kg) should produce about 60 ml of urine
hourly (1 ml/kg/hour). Dark, concentrated, and low volume of urine output should be
reported to the surgeon. Although other actions (B, C, and D) may be indicated, the
assessment findings should be reported to the healthcare provider.
The nurse is assessing a client who has a history of Parkinson's disease for
the past 5 years. What symptoms should this client most likely exhibit?
Loss of short-term memory, facial tics and grimaces, and constant writhing
movements.
Shuffling gait, masklike facial expression, and tremors of the head.
