HESI RN MEDICAL SURGICAL EXAM
QUESTIONS AND ANSWERS
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,
QUESTIONS AND ANSWERS
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,
