medsurg-hesi Questions with Detailed Verified
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 Ans: 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. Ans: 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. Ans: B)
Explain that the client will not be able to move her head throughout the CT scan.
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,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. Ans: 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?
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, 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." Ans: 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? Ans: 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? Ans: 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
© Get it right 2025 Getaway - Stuvia US All rights reserved
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 Ans: 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. Ans: 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. Ans: B)
Explain that the client will not be able to move her head throughout the CT scan.
© Get it right 2025 Getaway - Stuvia US All rights reserved
,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. Ans: 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?
© Get it right 2025 Getaway - Stuvia US All rights reserved
, 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." Ans: 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? Ans: 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? Ans: 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
© Get it right 2025 Getaway - Stuvia US All rights reserved
