HESI RN MEDICAL SURGICAL
EXAM PACK ALL QUESTIONS
AND VERIFIED ANSWERS 100%
CORRECT MED SURG EXAM
(NEW UPDATE)
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 - ANSWER-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. - ANSWER-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. -
ANSWER-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. - ANSWER-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." - ANSWER-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? - ANSWER-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? - ANSWER-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? - ANSWER-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.
EXAM PACK ALL QUESTIONS
AND VERIFIED ANSWERS 100%
CORRECT MED SURG EXAM
(NEW UPDATE)
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 - ANSWER-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. - ANSWER-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. -
ANSWER-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. - ANSWER-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." - ANSWER-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? - ANSWER-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? - ANSWER-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? - ANSWER-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.
