HESI RN MEDICAL SURGICAL EXAM
PACK 2024 QUESTIONS AND 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. - ✔✔- ANS: 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
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. - ✔✔- ANS: 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.
,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. - ✔✔- ANS: 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.
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. -
✔✔- ANS: 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.
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. - ✔✔- ANS:
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."
The normal range for cardiac output to ensure cerebral blood flow and oxygen
delivery is 4 to 8 L/min. - ✔✔- ANS: What is the normal range for cardiac
output?
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 - ✔✔- ANS: 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?
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. - ✔✔- ANS: What are plate guards?
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. - ✔✔- ANS: 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.
B) Place the objects Nancy needs for activities of daily living on the left side of
the table.
Rationale: Homonymous hemianopsia is loss of the visual field on the same side
as the paralyzed side. This results in the client neglecting that side of the body,
so it is beneficial to place objects on that side. Nancy had a left-hemisphere brain
attack so her right side is the weak side. Speaking slowly and clearly would
address the client's verbal deficits due to aphasia. Requesting all liquids to be
thickened would address dysphagia. Turning the client every 2 hours and
performing active range of motion exercises would address the client's risk for
immobility due to paralysis. - ✔✔- ANS: 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.
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.
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.
Rationale: This documentation provides the factual data of the events that
occurred. A)The nurse is making an assumption that the dizziness was caused
PACK 2024 QUESTIONS AND 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. - ✔✔- ANS: 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
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. - ✔✔- ANS: 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.
,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. - ✔✔- ANS: 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.
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. -
✔✔- ANS: 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.
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. - ✔✔- ANS:
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."
The normal range for cardiac output to ensure cerebral blood flow and oxygen
delivery is 4 to 8 L/min. - ✔✔- ANS: What is the normal range for cardiac
output?
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 - ✔✔- ANS: 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?
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. - ✔✔- ANS: What are plate guards?
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. - ✔✔- ANS: 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.
B) Place the objects Nancy needs for activities of daily living on the left side of
the table.
Rationale: Homonymous hemianopsia is loss of the visual field on the same side
as the paralyzed side. This results in the client neglecting that side of the body,
so it is beneficial to place objects on that side. Nancy had a left-hemisphere brain
attack so her right side is the weak side. Speaking slowly and clearly would
address the client's verbal deficits due to aphasia. Requesting all liquids to be
thickened would address dysphagia. Turning the client every 2 hours and
performing active range of motion exercises would address the client's risk for
immobility due to paralysis. - ✔✔- ANS: 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.
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.
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.
Rationale: This documentation provides the factual data of the events that
occurred. A)The nurse is making an assumption that the dizziness was caused
