medsurg-hesi | Questions with 100% Verified Answers |
Latest Update 2026/2027
Question: 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.
Question: 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.
,Question: 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.
Question: 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.
,Question: 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.
Question: 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.
Question: 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
Question: 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.
, Question: 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.
Answer: 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.
Question: 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.
Answer: 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.
Latest Update 2026/2027
Question: 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.
Question: 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.
,Question: 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.
Question: 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.
,Question: 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.
Question: 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.
Question: 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
Question: 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.
, Question: 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.
Answer: 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.
Question: 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.
Answer: 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.
