MED SURG II HESI QUESTIONS AND ANSWERS SURE
A+
✔✔in your own words, describe the glasgow coma scale - ✔✔An objective assessment
of the level of consciousness based on a score of 3 to 15, with scores of 7 or less
indicative of coma
✔✔list four nursing diagnoses for the comatose client in order of priority - ✔✔ineffective
breathing pattern
ineffective airway clearance
impaired gas exchange
decreased cardiac output
✔✔who is at risk for stroke? - ✔✔Persons with hx of HTN, previous TIA's, A-fib or
flutter, DM, oral contraceptive use and older adults
✔✔complications of immobility include the potential for thrombus development--3
nursing interventions to prevent this - ✔✔frequent ROM exercises
frequent position turns
avoidance of positions that decrease venous return
✔✔List four rationales for the appearance of restlessness in the unconscious client. -
✔✔anoxia
distended bladder
covert bleeding
return to conciousness
✔✔what nursing interventions prevent corneal drying in a comatose client? -
✔✔irrigation of eyes PRN w/ sterile prescribed solution
application of ophthalmic ointment q8h
close assessment for corneal ulceration or drying
, ✔✔When can a comatose client on IV hyperalimentation begin to receive tube feedings
instead? - ✔✔when peristalsis returns AEB active bowel sounds, passage of flatus or
bowel movement
✔✔what is the most important principle in bowel management program for a client with
neuro deficits? - ✔✔establishment of regularity
✔✔Define stroke - ✔✔disruption of blood flow to brain that results in sudden loss of
brain function
✔✔a client with a diagnosis of stroke presents with symptoms of aphasia and right
hemiparesis but no memory or hearing deficit..what hemisphere did the client
experience the stroke in? - ✔✔left
✔✔what are the symptoms of spinal shock? - ✔✔hypotension, bladder and bowel
distention, total paralysis, lack of sensation below lesion
✔✔what are the symptoms of autonomic dysreflexia? - ✔✔HTN, bladder and bowel
distention, exaggerated autonomic responses, headache, sweating, goose bumps, and
bradycardia
✔✔what is the most important indicator of increased ICP? - ✔✔a change in level of
responsiveness
✔✔What vital sign changes are indicative of increased ICP? - ✔✔increased BP
widening pulse pressure
increased/decreased pulse
respiratory irregularities
temperature increase
✔✔A neighbor calls the neighborhood nurse stating that he was knocked hard to the
floor by his very hyperactive dog. He is wondering what symptoms would indicate the
need to visit an emergency room. What should the nurse tell him to do? - ✔✔call HCP
now and inform him of fall
symptoms needing medical attention include: vertigo, confusion or any subtle behavior
change, headache, vomiting, ataxia, or seizure
✔✔what activities and situations that increase ICP should be avoided? - ✔✔change in
bed position
extreme hip flexion
endotracheal suctioning
compression of jugular veins
coughing
vomiting
A+
✔✔in your own words, describe the glasgow coma scale - ✔✔An objective assessment
of the level of consciousness based on a score of 3 to 15, with scores of 7 or less
indicative of coma
✔✔list four nursing diagnoses for the comatose client in order of priority - ✔✔ineffective
breathing pattern
ineffective airway clearance
impaired gas exchange
decreased cardiac output
✔✔who is at risk for stroke? - ✔✔Persons with hx of HTN, previous TIA's, A-fib or
flutter, DM, oral contraceptive use and older adults
✔✔complications of immobility include the potential for thrombus development--3
nursing interventions to prevent this - ✔✔frequent ROM exercises
frequent position turns
avoidance of positions that decrease venous return
✔✔List four rationales for the appearance of restlessness in the unconscious client. -
✔✔anoxia
distended bladder
covert bleeding
return to conciousness
✔✔what nursing interventions prevent corneal drying in a comatose client? -
✔✔irrigation of eyes PRN w/ sterile prescribed solution
application of ophthalmic ointment q8h
close assessment for corneal ulceration or drying
, ✔✔When can a comatose client on IV hyperalimentation begin to receive tube feedings
instead? - ✔✔when peristalsis returns AEB active bowel sounds, passage of flatus or
bowel movement
✔✔what is the most important principle in bowel management program for a client with
neuro deficits? - ✔✔establishment of regularity
✔✔Define stroke - ✔✔disruption of blood flow to brain that results in sudden loss of
brain function
✔✔a client with a diagnosis of stroke presents with symptoms of aphasia and right
hemiparesis but no memory or hearing deficit..what hemisphere did the client
experience the stroke in? - ✔✔left
✔✔what are the symptoms of spinal shock? - ✔✔hypotension, bladder and bowel
distention, total paralysis, lack of sensation below lesion
✔✔what are the symptoms of autonomic dysreflexia? - ✔✔HTN, bladder and bowel
distention, exaggerated autonomic responses, headache, sweating, goose bumps, and
bradycardia
✔✔what is the most important indicator of increased ICP? - ✔✔a change in level of
responsiveness
✔✔What vital sign changes are indicative of increased ICP? - ✔✔increased BP
widening pulse pressure
increased/decreased pulse
respiratory irregularities
temperature increase
✔✔A neighbor calls the neighborhood nurse stating that he was knocked hard to the
floor by his very hyperactive dog. He is wondering what symptoms would indicate the
need to visit an emergency room. What should the nurse tell him to do? - ✔✔call HCP
now and inform him of fall
symptoms needing medical attention include: vertigo, confusion or any subtle behavior
change, headache, vomiting, ataxia, or seizure
✔✔what activities and situations that increase ICP should be avoided? - ✔✔change in
bed position
extreme hip flexion
endotracheal suctioning
compression of jugular veins
coughing
vomiting
