An ER nurse is completing an assess-
ment on a patient that is alert but strug-
gles to answer questions. When she at-
tempts to talk, she slurs her speech and
appears very frightened. What addition-
al clinical manifestation does the nurse
a
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
Which clinical manifestation further sup-
ports an assessment of a left-sided brain
attack?
A) Visual field deficit on the left side. D
B) Spatial-perceptual deficits.
C) Paresthesia of the left side.
D) Global aphasia.
When preparing a patient for a noncon-
trast computed tomography (CT) scan
STAT, what nursing intervention should
the nurse implement?
A) Determine if the client has any aller-
gies to iodine
B) Explain that the client will not be able B
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.
A neurologist prescribes a magnetic res-
onance imaging (MRI) of the head STAT
for a patient. Which data warrants imme-
C
diate intervention by the nurse concern-
ing this diagnostic test?
A) Elevated blood pressure.
, Hesi Exit 4
B) Allergy to shell fish.
C) Right hip replacement.
D) History of atrial fibrillation.
A client's daughter is sitting by her moth-
er's bedside who was recently trans-
ferred 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 hap-
pened to my mother?" What is the best
response by the nurse?
A) "I am sorry, but according to the
B
Health Insurance Portability and Ac-
counting 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 moth-
er's serious condition."
What is the normal range for cardiac out-
4-8L/min
put?
A client was admitted with the diagnosis Thrombolytic therapy is contraindicated
of a brain attack. Their symptoms be- in clients with symptom onset longer than
gan 24 hours before being admitted. Why 3 hours prior to admission. This client
would this client not be a candidate for had symptoms for 24 hours before being
for thrombolytic therapy? brought to the medical center
Plate guards prevent food from being
pushed off the plate. Using plate guards
What are plate guards? and other assistive devices will encour-
age independence in a client with a
self-care deficit.
, Hesi Exit 4
Which condition is considered a
non-modifiable risk factor for a brain at-
tack?
A) High cholesterol levels. D
B) Obesity.
C) History of atrial fibrillation.
D) Advanced age.
A client is experiencing homonymous
hemianopsia as the result of a brain at-
tack. Which nursing intervention would
the nurse implement to address this con-
dition?
A) Turn Nancy every two hours and per-
form active range of motion exercises.
B) Place the objects Nancy needs for B
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.
A physical therapist (PT) places a gait
belt on a client and is assisting them
with ambulation from the bed to the chair.
As they get up out of the bed, they re-
port being dizzy and begin to fall. The
PT carefully allows them to fall back to
the bed and notifies the primary nurse.
Which written documentation should the
B
nurse put in the client's record?
A) Client experienced orthostatic hy-
potension when getting out of bed.
B) PT reported client complained of
dizziness when getting out of bed, and
gait belt was used to allow client to fall
back onto the bed.
C) PT notified the primary nurse that the
, Hesi Exit 4
client could not ambulate at this time be-
cause of dizziness.
D) Client had difficulty ambulating from
the bed to the chair when accompanied
by the PT, variance report completed.
A new nurse graduate is caring for a
postoperative client with the following
arterial blood gases (ABGs): pH, 7.30;
PCO2, 60 mm Hg; PO2, 80 mm Hg; bi-
carbonate, 24 mEq/L; and O2 saturation,
96%. Which of these actions by the new
graduate is indicated?
A
A) Encourage the client to use the incen-
tive spirometer and to cough.
B) Administer oxygen by nasal cannula.
C) Request a prescription for sodium bi-
carbonate from the health care provider.
D) Inform the charge nurse that no
changes in therapy are needed.
The nurse is providing dietary instruc-
tions to a 68-year-old client who is at
high risk for development of coronary
heart disease (CHD). Which information
should the nurse include?
A) Limit dietary selection of cholesterol
to 300 mg per day B
B) Increase intake of soluble fiber to 10
to 25 grams per day.
C) Decrease plant stanols and sterols to
less than 2 grams/day.
D) Ensure saturated fat is less than 30%
of total caloric intake.
A splint is prescribed for nighttime use by
a client with rheumatoid arthritis. Which
statement by the nurse provides the
A
most accurate explanation for use of the
splints?
A) Prevention of deformities.
ment on a patient that is alert but strug-
gles to answer questions. When she at-
tempts to talk, she slurs her speech and
appears very frightened. What addition-
al clinical manifestation does the nurse
a
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
Which clinical manifestation further sup-
ports an assessment of a left-sided brain
attack?
A) Visual field deficit on the left side. D
B) Spatial-perceptual deficits.
C) Paresthesia of the left side.
D) Global aphasia.
When preparing a patient for a noncon-
trast computed tomography (CT) scan
STAT, what nursing intervention should
the nurse implement?
A) Determine if the client has any aller-
gies to iodine
B) Explain that the client will not be able B
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.
A neurologist prescribes a magnetic res-
onance imaging (MRI) of the head STAT
for a patient. Which data warrants imme-
C
diate intervention by the nurse concern-
ing this diagnostic test?
A) Elevated blood pressure.
, Hesi Exit 4
B) Allergy to shell fish.
C) Right hip replacement.
D) History of atrial fibrillation.
A client's daughter is sitting by her moth-
er's bedside who was recently trans-
ferred 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 hap-
pened to my mother?" What is the best
response by the nurse?
A) "I am sorry, but according to the
B
Health Insurance Portability and Ac-
counting 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 moth-
er's serious condition."
What is the normal range for cardiac out-
4-8L/min
put?
A client was admitted with the diagnosis Thrombolytic therapy is contraindicated
of a brain attack. Their symptoms be- in clients with symptom onset longer than
gan 24 hours before being admitted. Why 3 hours prior to admission. This client
would this client not be a candidate for had symptoms for 24 hours before being
for thrombolytic therapy? brought to the medical center
Plate guards prevent food from being
pushed off the plate. Using plate guards
What are plate guards? and other assistive devices will encour-
age independence in a client with a
self-care deficit.
, Hesi Exit 4
Which condition is considered a
non-modifiable risk factor for a brain at-
tack?
A) High cholesterol levels. D
B) Obesity.
C) History of atrial fibrillation.
D) Advanced age.
A client is experiencing homonymous
hemianopsia as the result of a brain at-
tack. Which nursing intervention would
the nurse implement to address this con-
dition?
A) Turn Nancy every two hours and per-
form active range of motion exercises.
B) Place the objects Nancy needs for B
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.
A physical therapist (PT) places a gait
belt on a client and is assisting them
with ambulation from the bed to the chair.
As they get up out of the bed, they re-
port being dizzy and begin to fall. The
PT carefully allows them to fall back to
the bed and notifies the primary nurse.
Which written documentation should the
B
nurse put in the client's record?
A) Client experienced orthostatic hy-
potension when getting out of bed.
B) PT reported client complained of
dizziness when getting out of bed, and
gait belt was used to allow client to fall
back onto the bed.
C) PT notified the primary nurse that the
, Hesi Exit 4
client could not ambulate at this time be-
cause of dizziness.
D) Client had difficulty ambulating from
the bed to the chair when accompanied
by the PT, variance report completed.
A new nurse graduate is caring for a
postoperative client with the following
arterial blood gases (ABGs): pH, 7.30;
PCO2, 60 mm Hg; PO2, 80 mm Hg; bi-
carbonate, 24 mEq/L; and O2 saturation,
96%. Which of these actions by the new
graduate is indicated?
A
A) Encourage the client to use the incen-
tive spirometer and to cough.
B) Administer oxygen by nasal cannula.
C) Request a prescription for sodium bi-
carbonate from the health care provider.
D) Inform the charge nurse that no
changes in therapy are needed.
The nurse is providing dietary instruc-
tions to a 68-year-old client who is at
high risk for development of coronary
heart disease (CHD). Which information
should the nurse include?
A) Limit dietary selection of cholesterol
to 300 mg per day B
B) Increase intake of soluble fiber to 10
to 25 grams per day.
C) Decrease plant stanols and sterols to
less than 2 grams/day.
D) Ensure saturated fat is less than 30%
of total caloric intake.
A splint is prescribed for nighttime use by
a client with rheumatoid arthritis. Which
statement by the nurse provides the
A
most accurate explanation for use of the
splints?
A) Prevention of deformities.
