Med Surg Hesi Quiz (Qs Correctly
Answered)
The nurse is planning care for a client who has a right hemispheric stroke.
Which nursing diagnosis should the nurse include in the plan of care?
A Impaired physical mobility related to right-sided hemiplegia.
B Risk for injury related to denial of deficits and impulsiveness.
C Impaired verbal communication related to speech-language deficits.
D Ineffective coping related to depression and distress about disability.
✔️Ans -B) Risk for injury related to denial of deficits and impulsiveness.
With right-brain damage, a client experience difficulty in judgment and spatial
perception and is more likely to be impulsive and move quickly, which placing
the client at risk for falls (B). Although clients with right and left hemisphere
damage may experience impaired physical mobility, the client with right brain
damage will manifest physical impairments on the contralateral side of the
body, not the same side (A). The client with a left-brain injury may manifest
right-sided hemiplegia with speech or language deficits (C). A client with left-
brain damage is more likely to be aware of the deficits and experience grief
related to physical impairment and depression (D).
After checking the urinary drainage system for kinks in the tubing, the nurse
determines that a client who has returned from the post-anesthesia care has a
dark, concentrated urinary output of 54 ml for the last 2 hours. What priority
nursing action should be implemented?
A Report the findings to the surgeon.
B Irrigate the indwelling urinary catheter.
C Apply manual pressure to the bladder.
D Increase the IV flow rate for 15 minutes. ✔️Ans -A) Report the findings
to the surgeon.
An adult who weighs 132 pounds (60 kg) should produce about 60 ml of urine
hourly (1 ml/kg/hour). Dark, concentrated, and low volume of urine output
should be reported to the surgeon. Although other actions (B, C, and D) may
be indicated, the assessment findings should be reported to the healthcare
provider.
,The nurse is assessing a client who has a history of Parkinson's disease for the
past 5 years. What symptoms should this client most likely exhibit?
Loss of short-term memory, facial tics and grimaces, and constant writhing
movements.
Shuffling gait, masklike facial expression, and tremors of the head.
Extreme muscular weakness, easy fatigability, and ptosis.
Numbness of the extremities, loss of balance, and visual disturbances.
✔️Ans -B) Shuffling gait, masklike facial expression, and tremors of the head.
(B) are common clinical features of Parkinsonism. (A) are symptoms of
chorea, (C) of myasthenia gravis, and (D) of multiple sclerosis.
A splint is prescribed for nighttime use by a client with rheumatoid arthritis.
Which statement by the nurse provides the most accurate explanation for use
of the splints?
Prevention of deformities.
Avoidance of joint trauma.
Relief of joint inflammation.
Improvement in joint strength. ✔️Ans -A) Prevention of deformities.
Splints may be used at night by clients with rheumatoid arthritis to prevent
deformities (A) caused by muscle spasms and contractures. Splints are not
used for (B). (C) is usually treated with medications, particularly those
classified as non-steroidal antiinflammatory drugs (NSAIDs). For (D), a
prescribed exercise program is indicated.
The nurse working in a postoperative surgical clinic is assessing a woman
who had a left radical mastectomy for breast cancer. Which factor puts this
client at greatest risk for developing lymphedema?
She sustained an insect bite to her left arm yesterday.
She has lost twenty pounds since the surgery.
Her healthcare provider now prescribes a calcium channel blocker for
hypertension.
Her hobby is playing classical music on the piano. ✔️Ans -A) She
sustained an insect bite to her left arm yesterday.
A radical mastectomy interrupts lymph flow, and the increased lymph flow
that occurs in response to the insect bite increases the risk for the occurrence
of lymphedema (A). (B) is not a factor. Lymphedema is not significantly
, related to vascular circulation (C). Only overuse of the arm, such as weight-
lifting, would cause lymphedema--(D) would not.
A client is placed on a respirator following a cerebral hemorrhage, and
vecuronium bromide (Norcuron) 0.04 mg/kg q12h IV is prescribed. Which
nursing diagnosis is the priority for this client?
Impaired communication related to paralysis of skeletal muscles.
High risk for infection related to increased intracranial pressure.
Potential for injury related to impaired lung expansion.
Social isolation related to inability to communicate. ✔️Ans -A) Impaired
communication related to paralysis of skeletal muscles.
To increase the client's tolerance of endotracheal intubation and/or
mechanical ventilation, a skeletal-muscle relaxant such as vecuronium is
usually prescribed. Impaired communication (A) is a serious outcome because
the client cannot communicate his/her needs. Although this client might also
experience (D), it is not a priority when compared to (A). Infection is not
related to increased intracranial pressure (B). The respirator will ensure that
the lungs are expanded (C).
Dysrhythmias are a concern for any client. However, the presence of a
dysrhythmia is more serious in an elderly person because
elderly persons usually live alone and cannot summon help when symptoms
appear.
elderly persons are more likely to eat high-fat diets which make them
susceptible to heart disease.
cardiac symptoms, such as confusion, are more difficult to recognize in the
elderly.
elderly persons are intolerant of decreased cardiac output which may result
in dizziness and falls. ✔️Ans -D) elderly persons are intolerant of
decreased cardiac output which may result in dizziness and falls.
Cardiac output is decreased with aging (D). Because of loss of contractility and
elasticity, blood flow is decreased and tachycardia is poorly tolerated.
Therefore, if an elderly person experiences dysrhythmia (tachycardia or
bradycardia), further compromising their cardiac output, they are more likely
to experience syncope, falls, transient ischemic attacks, and possibly
dementia. Most elderly persons do not eat high-fat diets (B) and most are not
Answered)
The nurse is planning care for a client who has a right hemispheric stroke.
Which nursing diagnosis should the nurse include in the plan of care?
A Impaired physical mobility related to right-sided hemiplegia.
B Risk for injury related to denial of deficits and impulsiveness.
C Impaired verbal communication related to speech-language deficits.
D Ineffective coping related to depression and distress about disability.
✔️Ans -B) Risk for injury related to denial of deficits and impulsiveness.
With right-brain damage, a client experience difficulty in judgment and spatial
perception and is more likely to be impulsive and move quickly, which placing
the client at risk for falls (B). Although clients with right and left hemisphere
damage may experience impaired physical mobility, the client with right brain
damage will manifest physical impairments on the contralateral side of the
body, not the same side (A). The client with a left-brain injury may manifest
right-sided hemiplegia with speech or language deficits (C). A client with left-
brain damage is more likely to be aware of the deficits and experience grief
related to physical impairment and depression (D).
After checking the urinary drainage system for kinks in the tubing, the nurse
determines that a client who has returned from the post-anesthesia care has a
dark, concentrated urinary output of 54 ml for the last 2 hours. What priority
nursing action should be implemented?
A Report the findings to the surgeon.
B Irrigate the indwelling urinary catheter.
C Apply manual pressure to the bladder.
D Increase the IV flow rate for 15 minutes. ✔️Ans -A) Report the findings
to the surgeon.
An adult who weighs 132 pounds (60 kg) should produce about 60 ml of urine
hourly (1 ml/kg/hour). Dark, concentrated, and low volume of urine output
should be reported to the surgeon. Although other actions (B, C, and D) may
be indicated, the assessment findings should be reported to the healthcare
provider.
,The nurse is assessing a client who has a history of Parkinson's disease for the
past 5 years. What symptoms should this client most likely exhibit?
Loss of short-term memory, facial tics and grimaces, and constant writhing
movements.
Shuffling gait, masklike facial expression, and tremors of the head.
Extreme muscular weakness, easy fatigability, and ptosis.
Numbness of the extremities, loss of balance, and visual disturbances.
✔️Ans -B) Shuffling gait, masklike facial expression, and tremors of the head.
(B) are common clinical features of Parkinsonism. (A) are symptoms of
chorea, (C) of myasthenia gravis, and (D) of multiple sclerosis.
A splint is prescribed for nighttime use by a client with rheumatoid arthritis.
Which statement by the nurse provides the most accurate explanation for use
of the splints?
Prevention of deformities.
Avoidance of joint trauma.
Relief of joint inflammation.
Improvement in joint strength. ✔️Ans -A) Prevention of deformities.
Splints may be used at night by clients with rheumatoid arthritis to prevent
deformities (A) caused by muscle spasms and contractures. Splints are not
used for (B). (C) is usually treated with medications, particularly those
classified as non-steroidal antiinflammatory drugs (NSAIDs). For (D), a
prescribed exercise program is indicated.
The nurse working in a postoperative surgical clinic is assessing a woman
who had a left radical mastectomy for breast cancer. Which factor puts this
client at greatest risk for developing lymphedema?
She sustained an insect bite to her left arm yesterday.
She has lost twenty pounds since the surgery.
Her healthcare provider now prescribes a calcium channel blocker for
hypertension.
Her hobby is playing classical music on the piano. ✔️Ans -A) She
sustained an insect bite to her left arm yesterday.
A radical mastectomy interrupts lymph flow, and the increased lymph flow
that occurs in response to the insect bite increases the risk for the occurrence
of lymphedema (A). (B) is not a factor. Lymphedema is not significantly
, related to vascular circulation (C). Only overuse of the arm, such as weight-
lifting, would cause lymphedema--(D) would not.
A client is placed on a respirator following a cerebral hemorrhage, and
vecuronium bromide (Norcuron) 0.04 mg/kg q12h IV is prescribed. Which
nursing diagnosis is the priority for this client?
Impaired communication related to paralysis of skeletal muscles.
High risk for infection related to increased intracranial pressure.
Potential for injury related to impaired lung expansion.
Social isolation related to inability to communicate. ✔️Ans -A) Impaired
communication related to paralysis of skeletal muscles.
To increase the client's tolerance of endotracheal intubation and/or
mechanical ventilation, a skeletal-muscle relaxant such as vecuronium is
usually prescribed. Impaired communication (A) is a serious outcome because
the client cannot communicate his/her needs. Although this client might also
experience (D), it is not a priority when compared to (A). Infection is not
related to increased intracranial pressure (B). The respirator will ensure that
the lungs are expanded (C).
Dysrhythmias are a concern for any client. However, the presence of a
dysrhythmia is more serious in an elderly person because
elderly persons usually live alone and cannot summon help when symptoms
appear.
elderly persons are more likely to eat high-fat diets which make them
susceptible to heart disease.
cardiac symptoms, such as confusion, are more difficult to recognize in the
elderly.
elderly persons are intolerant of decreased cardiac output which may result
in dizziness and falls. ✔️Ans -D) elderly persons are intolerant of
decreased cardiac output which may result in dizziness and falls.
Cardiac output is decreased with aging (D). Because of loss of contractility and
elasticity, blood flow is decreased and tachycardia is poorly tolerated.
Therefore, if an elderly person experiences dysrhythmia (tachycardia or
bradycardia), further compromising their cardiac output, they are more likely
to experience syncope, falls, transient ischemic attacks, and possibly
dementia. Most elderly persons do not eat high-fat diets (B) and most are not
