HESI RN MEDICAL SURGICAL EXAM PACK 2024 QUESTIONS AND ANSWE
Study online at https://quizlet.com/_f5ztxq
1. An ER nurse is completing an assess- A) A carotid bruit.
ment on a patient that is alert but strug-
gles to answer questions. When she at- Rationale: the carotid artery (artery to the
tempts to talk, she slurs her speech and brain) is narrowed in clients with a brain at-
appears very frightened. What addition- tack. A bruit is an abnormal sound heard on
al clinical manifestation does the nurse auscultation resulting from interference with
expect to find if nacy's sysmptoms have normal blood flow. Usually the blood pres-
been caused by a brain attack (stroke)? sure is hypertensive. Initially flaccid paralysis
occurs, resulting in hyporefkexic deep ten-
A. A carotid bruit don reflexes. Bowel sounds are not indicative
B. A hypotensive blood pressure of a brain attack.
C. hyperreflexic deep tendon relexes.
D. Decreased bowel sounds
2. Which clinical manifestation further sup- D) Global aphasia.
ports an assessment of a left-sided brain
attack? Rationale: Global aphasia refers to difficulty
speaking, listening, and understanding, as
A) Visual field deficit on the left side. well as difficulty reading and writing. Symp-
B) Spatial-perceptual deficits. toms vary from person to person. Apha-
C) Paresthesia of the left side. sia may occur secondary to any brain in-
D) Global aphasia. jury involving the left hemisphere. Visual
D) Global aphasia. field deficits, spatial-perceptual deficits, and
paresthsia of the left side usually occur with
right-sided brain attack.
3. When preparing a patient for a noncon- B) Explain that the client will not be able to
trast computed tomography (CT) scan move her head throughout the CT scan.
STAT, what nursing intervention should
the nurse implement? Rationale: Because head motion will distort
the images, Nancy will have to remain still
A) Determine if the client has any allergies throughout the procedure. Allergies to iodine
, HESI RN MEDICAL SURGICAL EXAM PACK 2024 QUESTIONS AND ANSWE
Study online at https://quizlet.com/_f5ztxq
to iodine is important if contrast dye is being used
B) Explain that the client will not be able to for the CT scan. Premedicating the client to
move her head throughout the CT scan. decrease pain prior to the procedure is un-
C) Premedicate the client to decrease pain necessary because CT scanning is a nonin-
prior to having the procedure. vasive and painless procedure. Providing an
D) Provide an explanation of relaxation explanation of relaxation exercises prior to
exercises prior to the procedure. the procedure is a worthwhile intervention to
decrease anxiety but is not of highest priority.
4. A neurologist prescribes a magnetic reso- C) Right hip replacement.
nance imaging (MRI) of the head STAT for
a patient. Which data warrants immedi- The magnetic field generated by the MRI
ate intervention by the nurse concerning is so strong that metal-containing items are
this diagnostic test? strongly attracted to the magnet. Because
the hip joint is made of metal, a lead shield
A) Elevated blood pressure. must be used during the procedure. Elevated
B) Allergy to shell fish. blood pressure, an allergy to shell fish, and
C) Right hip replacement. a history of atrial fibrillation would not affect
D) History of atrial fibrillation. the MRI.
5. A client's daughter is sitting by her moth- B) "Your mother has had a stroke, and
er's bedside who was recently transferred the blood supply to the brain has been
to the Intermediate Care Unit. She states blocked."
"I don't understand what a brain attack
is. The healthcare provider told me my Rationale: The nurse can discuss what a di-
mother is in serious condition and they agnosis means. Nancy is unable to make
are going to run several tests. I just don't decisions, so the next of kin, her daughter,
know what is going on. What happened Gail, needs sufficient information to make in-
to my mother?" What is the best response formed decisions. The nurse has the knowl-
by the nurse? edge, and the responsibility, to explain Nan-
cy's condition to Gail. The nurse should give
A) "I am sorry, but according to the Health
, HESI RN MEDICAL SURGICAL EXAM PACK 2024 QUESTIONS AND ANSWE
Study online at https://quizlet.com/_f5ztxq
Insurance Portability and Accounting Act facts first, and then address her feelings after
(HIPAA), I cannot give you any informa- the information is provided.
tion."
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."
6. What is the normal range for cardiac out- The normal range for cardiac output to en-
put? sure cerebral blood flow and oxygen delivery
is 4 to 8 L/min.
7. A client was admitted with the diagno- Thrombolytic therapy is contraindicated in
sis of a brain attack. Their symptoms be- clients with symptom onset longer than 3
gan 24 hours before being admitted. Why hours prior to admission. This client had
would this client not be a candidate for for symptoms for 24 hours before being brought
thrombolytic therapy? to the medical center
8. What are plate guards? Plate guards prevent food from being
pushed off the plate. Using plate guards and
other assistive devices will encourage inde-
pendence in a client with a self-care deficit.
9. Which condition is considered a D) Advanced age.
non-modifiable risk factor for a brain at-
tack? Rationale: People over age 55 are a high-risk
group for a brain attack because the in-
A) High cholesterol levels. cidence of stroke more than doubles in
B) Obesity. each successive decade of life. Non-modifi-
, HESI RN MEDICAL SURGICAL EXAM PACK 2024 QUESTIONS AND ANSWE
Study online at https://quizlet.com/_f5ztxq
C) History of atrial fibrillation. able means the client cannot do anything to
D) Advanced age. change the risk factor. All the other options
are modifiable risk factors.
10. A client is experiencing homonymous B) Place the objects Nancy needs for activities
hemianopsia as the result of a brain at- of daily living on the left side of the table.
tack. Which nursing intervention would
the nurse implement to address this con- Rationale: Homonymous hemianopsia is loss
dition? of the visual field on the same side as the
paralyzed side. This results in the client ne-
A) Turn Nancy every two hours and per- glecting that side of the body, so it is benefi-
form active range of motion exercises. cial to place objects on that side. Nancy had a
B) Place the objects Nancy needs for ac- left-hemisphere brain attack so her right side
tivities of daily living on the left side of the is the weak side. Speaking slowly and clearly
table. would address the client's verbal deficits due
C) Speak slowly and clearly to assist Nancy to aphasia. Requesting all liquids to be thick-
in forming sounds to words. ened would address dysphagia. Turning the
D) Request that the dietary department client every 2 hours and performing active
thicken all liquids on Nancy's meal and range of motion exercises would address the
snack trays. client's risk for immobility due to paralysis.
11. A physical therapist (PT) places a gait belt B) PT reported client complained of dizziness
on a client and is assisting them with am- when getting out of bed, and gait belt was
bulation from the bed to the chair. As they used to allow client to fall back onto the bed.
get up out of the bed, they report being
dizzy and begin to fall. The PT carefully Rationale: This documentation provides the
allows them to fall back to the bed and factual data of the events that occurred. A)The
notifies the primary nurse. Which written nurse is making an assumption that the dizzi-
documentation should the nurse put in ness was caused by orthostatic hypotension.
the client's record? C) Not all the pertinent facts are included in
this documentation.
A) Client experienced orthostatic hy-
Study online at https://quizlet.com/_f5ztxq
1. An ER nurse is completing an assess- A) A carotid bruit.
ment on a patient that is alert but strug-
gles to answer questions. When she at- Rationale: the carotid artery (artery to the
tempts to talk, she slurs her speech and brain) is narrowed in clients with a brain at-
appears very frightened. What addition- tack. A bruit is an abnormal sound heard on
al clinical manifestation does the nurse auscultation resulting from interference with
expect to find if nacy's sysmptoms have normal blood flow. Usually the blood pres-
been caused by a brain attack (stroke)? sure is hypertensive. Initially flaccid paralysis
occurs, resulting in hyporefkexic deep ten-
A. A carotid bruit don reflexes. Bowel sounds are not indicative
B. A hypotensive blood pressure of a brain attack.
C. hyperreflexic deep tendon relexes.
D. Decreased bowel sounds
2. Which clinical manifestation further sup- D) Global aphasia.
ports an assessment of a left-sided brain
attack? Rationale: Global aphasia refers to difficulty
speaking, listening, and understanding, as
A) Visual field deficit on the left side. well as difficulty reading and writing. Symp-
B) Spatial-perceptual deficits. toms vary from person to person. Apha-
C) Paresthesia of the left side. sia may occur secondary to any brain in-
D) Global aphasia. jury involving the left hemisphere. Visual
D) Global aphasia. field deficits, spatial-perceptual deficits, and
paresthsia of the left side usually occur with
right-sided brain attack.
3. When preparing a patient for a noncon- B) Explain that the client will not be able to
trast computed tomography (CT) scan move her head throughout the CT scan.
STAT, what nursing intervention should
the nurse implement? Rationale: Because head motion will distort
the images, Nancy will have to remain still
A) Determine if the client has any allergies throughout the procedure. Allergies to iodine
, HESI RN MEDICAL SURGICAL EXAM PACK 2024 QUESTIONS AND ANSWE
Study online at https://quizlet.com/_f5ztxq
to iodine is important if contrast dye is being used
B) Explain that the client will not be able to for the CT scan. Premedicating the client to
move her head throughout the CT scan. decrease pain prior to the procedure is un-
C) Premedicate the client to decrease pain necessary because CT scanning is a nonin-
prior to having the procedure. vasive and painless procedure. Providing an
D) Provide an explanation of relaxation explanation of relaxation exercises prior to
exercises prior to the procedure. the procedure is a worthwhile intervention to
decrease anxiety but is not of highest priority.
4. A neurologist prescribes a magnetic reso- C) Right hip replacement.
nance imaging (MRI) of the head STAT for
a patient. Which data warrants immedi- The magnetic field generated by the MRI
ate intervention by the nurse concerning is so strong that metal-containing items are
this diagnostic test? strongly attracted to the magnet. Because
the hip joint is made of metal, a lead shield
A) Elevated blood pressure. must be used during the procedure. Elevated
B) Allergy to shell fish. blood pressure, an allergy to shell fish, and
C) Right hip replacement. a history of atrial fibrillation would not affect
D) History of atrial fibrillation. the MRI.
5. A client's daughter is sitting by her moth- B) "Your mother has had a stroke, and
er's bedside who was recently transferred the blood supply to the brain has been
to the Intermediate Care Unit. She states blocked."
"I don't understand what a brain attack
is. The healthcare provider told me my Rationale: The nurse can discuss what a di-
mother is in serious condition and they agnosis means. Nancy is unable to make
are going to run several tests. I just don't decisions, so the next of kin, her daughter,
know what is going on. What happened Gail, needs sufficient information to make in-
to my mother?" What is the best response formed decisions. The nurse has the knowl-
by the nurse? edge, and the responsibility, to explain Nan-
cy's condition to Gail. The nurse should give
A) "I am sorry, but according to the Health
, HESI RN MEDICAL SURGICAL EXAM PACK 2024 QUESTIONS AND ANSWE
Study online at https://quizlet.com/_f5ztxq
Insurance Portability and Accounting Act facts first, and then address her feelings after
(HIPAA), I cannot give you any informa- the information is provided.
tion."
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."
6. What is the normal range for cardiac out- The normal range for cardiac output to en-
put? sure cerebral blood flow and oxygen delivery
is 4 to 8 L/min.
7. A client was admitted with the diagno- Thrombolytic therapy is contraindicated in
sis of a brain attack. Their symptoms be- clients with symptom onset longer than 3
gan 24 hours before being admitted. Why hours prior to admission. This client had
would this client not be a candidate for for symptoms for 24 hours before being brought
thrombolytic therapy? to the medical center
8. What are plate guards? Plate guards prevent food from being
pushed off the plate. Using plate guards and
other assistive devices will encourage inde-
pendence in a client with a self-care deficit.
9. Which condition is considered a D) Advanced age.
non-modifiable risk factor for a brain at-
tack? Rationale: People over age 55 are a high-risk
group for a brain attack because the in-
A) High cholesterol levels. cidence of stroke more than doubles in
B) Obesity. each successive decade of life. Non-modifi-
, HESI RN MEDICAL SURGICAL EXAM PACK 2024 QUESTIONS AND ANSWE
Study online at https://quizlet.com/_f5ztxq
C) History of atrial fibrillation. able means the client cannot do anything to
D) Advanced age. change the risk factor. All the other options
are modifiable risk factors.
10. A client is experiencing homonymous B) Place the objects Nancy needs for activities
hemianopsia as the result of a brain at- of daily living on the left side of the table.
tack. Which nursing intervention would
the nurse implement to address this con- Rationale: Homonymous hemianopsia is loss
dition? of the visual field on the same side as the
paralyzed side. This results in the client ne-
A) Turn Nancy every two hours and per- glecting that side of the body, so it is benefi-
form active range of motion exercises. cial to place objects on that side. Nancy had a
B) Place the objects Nancy needs for ac- left-hemisphere brain attack so her right side
tivities of daily living on the left side of the is the weak side. Speaking slowly and clearly
table. would address the client's verbal deficits due
C) Speak slowly and clearly to assist Nancy to aphasia. Requesting all liquids to be thick-
in forming sounds to words. ened would address dysphagia. Turning the
D) Request that the dietary department client every 2 hours and performing active
thicken all liquids on Nancy's meal and range of motion exercises would address the
snack trays. client's risk for immobility due to paralysis.
11. A physical therapist (PT) places a gait belt B) PT reported client complained of dizziness
on a client and is assisting them with am- when getting out of bed, and gait belt was
bulation from the bed to the chair. As they used to allow client to fall back onto the bed.
get up out of the bed, they report being
dizzy and begin to fall. The PT carefully Rationale: This documentation provides the
allows them to fall back to the bed and factual data of the events that occurred. A)The
notifies the primary nurse. Which written nurse is making an assumption that the dizzi-
documentation should the nurse put in ness was caused by orthostatic hypotension.
the client's record? C) Not all the pertinent facts are included in
this documentation.
A) Client experienced orthostatic hy-
