HESI RN MEDICAL SURGICAL EXAM
PACK 2024 QUESTIONS AND ANSWERS
ACTUAL QUESTIONS AND CORRECT
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 - CORRECT ANSWERS 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. - CORRECT ANSWERS 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. -
CORRECT ANSWERS 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. - CORRECT ANSWERS 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." - CORRECT ANSWERS 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? - CORRECT ANSWERS
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? - CORRECT ANSWERS 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? - CORRECT ANSWERS 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. - CORRECT ANSWERS 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.
PACK 2024 QUESTIONS AND ANSWERS
ACTUAL QUESTIONS AND CORRECT
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 - CORRECT ANSWERS 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. - CORRECT ANSWERS 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. -
CORRECT ANSWERS 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. - CORRECT ANSWERS 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." - CORRECT ANSWERS 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? - CORRECT ANSWERS
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? - CORRECT ANSWERS 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? - CORRECT ANSWERS 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. - CORRECT ANSWERS 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.
