HESI RN MEDICAL SURGICAL EXAM questions
well answered already passed (updated)
A) A carotid bruit.
1. An ER nurse is completing an assess-
ment on a patient that is alert but strug- Rationale: the carotid artery (artery to the
gles to answer questions. When she at- brain) is narrowed in clients with a brain at-
tempts to talk, she slurs her speech and tack. A bruit is an abnormal sound heard on
appears very frightened. What addition- auscultation resulting from interference with
al clinical manifestation does the nurse normal blood flow. Usually the blood pres-
expect to find if navy’s symptoms have sure is hypertensive. Initially flaccid paralysis
been caused by a brain attack (stroke)? occurs, resulting in hyporeflexia deep ten-
don reflexes. Bowel sounds are not indicative
A. A carotid bruit
of a brain attack.
B. A hypotensive blood pressure
C. hyperreflexia deep tendon relaxes.
D. Decreased bowel sounds
D) Global aphasia.
2. Which clinical manifestation further sup-
ports an assessment of a left-sided brain Rationale: Global aphasia refers to difficulty
attack? speaking, listening, and understanding, as
well as difficulty reading and writing. Symp-
A) Visual field deficit on the left side.
toms vary from person to person. Apha-
B) Spatial-perceptual deficits.
sia may occur secondary to any brain in-
C) Paresthesia of the left side.
jury involving the left hemisphere. Visual
D) Global aphasia.
field deficits, spatial-perceptual deficits, and
D) Global aphasia.
paresthesia of the left side usually occur with
right-sided brain attack.
B) Explain that the client will not be able to
3. When preparing a patient for a noncon-
move her head throughout the CT scan.
trast computed tomography (CT) scan
STAT, what nursing intervention should Rationale: Because head motion will distort
the nurse implement? the images, Nancy will have to remain still
A) Determine if the client has any allergies throughout the procedure. Allergies to iodine
,HESI RN MEDICAL SURGICAL EXAM questions
well answered already passed (updated)
to iodine is important if contrast dye is being used
B) Explain that the client will not be able to for the CT scan. Premedicating the client to
move her head throughout the CT scan. decrease pain prior to the procedure is un-
C) Premedicate the client to decrease pain necessary because CT scanning is a nonin-
prior to having the procedure. vasive and painless procedure. Providing an
D) Provide an explanation of relaxation explanation of relaxation exercises prior to
exercises prior to the procedure. the procedure is a worthwhile intervention to
decrease anxiety but is not of highest priority.
4. A neurologist prescribes a magnetic Reso- C) Right hip replacement.
nance imaging (MRI) of the head STAT for
a patient. Which data warrants immedi- The magnetic field generated by the MRI
ate intervention by the nurse concerning is so strong that metal-containing items are
this diagnostic test? strongly attracted to the magnet. Because
the hip joint is made of metal, a lead shield
A) Elevated blood pressure. must be used during the procedure. Elevated
B) Allergy to shell fish. blood pressure, an allergy to shell fish, and
C) Right hip replacement. a history of atrial fibrillation would not attect
D) History of atrial fibrillation. the MRI.
5. A client's daughter is sitting by her moth- B) "Your mother has had a stroke, and
er's bedside who was recently transferred the blood supply to the brain has been
to the Intermediate Care Unit. She states blocked."
"I don't understand what a brain attack
is. The healthcare provider told me my Rationale: The nurse can discuss what a di-
mother is in serious condition and they agnosis means. Nancy is unable to make
are going to run several tests. I just don't decisions, so the next of kin, her daughter,
know what is going on. What happened Gail, needs sufficient information to make in-
to my mother?" What is the best response formed decisions. The nurse has the knowl-
by the nurse? A) "I am sorry, but
according to the health
,HESI RN MEDICAL SURGICAL EXAM questions
well answered already passed (updated)
edge, and the responsibility, to explain Nan- cy's condition to Gail.
The nurse should give
, HESI RN MEDICAL SURGICAL EXAM questions
well answered already passed (updated)
Insurance Portability and Accounting Act facts first, and then address her feelings after
(HIPAA), I cannot give you any informa- the information is provided.
tion."
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 moth-
er's serious condition."
6. What is the normal range for cardiac out- The normal range for cardiac output to en-
put? sure cerebral blood flow and oxygen delivery
is 4 to 8 L/min.
7. A client was admitted with the diagno- Thrombolytic therapy is contraindicated in
sis of a brain attack. Their symptoms be- clients with symptom onset longer than 3
gan 24 hours before being admitted. Why hours prior to admission. This client had
would this client not be a candidate for symptoms for 24 hours before being brought
thrombolytic therapy? to the medical center
8. What are plate guards? Plate guards prevent food from being
pushed Ott the plate. Using plate guards and
other assistive devices will encourage inde-
pendence in a client with a self-care deficit.
9. Which condition is considered a
A) High cholesterol levels.
non-modifiable risk factor for a brain at-
B) Obesity.
tack?
well answered already passed (updated)
A) A carotid bruit.
1. An ER nurse is completing an assess-
ment on a patient that is alert but strug- Rationale: the carotid artery (artery to the
gles to answer questions. When she at- brain) is narrowed in clients with a brain at-
tempts to talk, she slurs her speech and tack. A bruit is an abnormal sound heard on
appears very frightened. What addition- auscultation resulting from interference with
al clinical manifestation does the nurse normal blood flow. Usually the blood pres-
expect to find if navy’s symptoms have sure is hypertensive. Initially flaccid paralysis
been caused by a brain attack (stroke)? occurs, resulting in hyporeflexia deep ten-
don reflexes. Bowel sounds are not indicative
A. A carotid bruit
of a brain attack.
B. A hypotensive blood pressure
C. hyperreflexia deep tendon relaxes.
D. Decreased bowel sounds
D) Global aphasia.
2. Which clinical manifestation further sup-
ports an assessment of a left-sided brain Rationale: Global aphasia refers to difficulty
attack? speaking, listening, and understanding, as
well as difficulty reading and writing. Symp-
A) Visual field deficit on the left side.
toms vary from person to person. Apha-
B) Spatial-perceptual deficits.
sia may occur secondary to any brain in-
C) Paresthesia of the left side.
jury involving the left hemisphere. Visual
D) Global aphasia.
field deficits, spatial-perceptual deficits, and
D) Global aphasia.
paresthesia of the left side usually occur with
right-sided brain attack.
B) Explain that the client will not be able to
3. When preparing a patient for a noncon-
move her head throughout the CT scan.
trast computed tomography (CT) scan
STAT, what nursing intervention should Rationale: Because head motion will distort
the nurse implement? the images, Nancy will have to remain still
A) Determine if the client has any allergies throughout the procedure. Allergies to iodine
,HESI RN MEDICAL SURGICAL EXAM questions
well answered already passed (updated)
to iodine is important if contrast dye is being used
B) Explain that the client will not be able to for the CT scan. Premedicating the client to
move her head throughout the CT scan. decrease pain prior to the procedure is un-
C) Premedicate the client to decrease pain necessary because CT scanning is a nonin-
prior to having the procedure. vasive and painless procedure. Providing an
D) Provide an explanation of relaxation explanation of relaxation exercises prior to
exercises prior to the procedure. the procedure is a worthwhile intervention to
decrease anxiety but is not of highest priority.
4. A neurologist prescribes a magnetic Reso- C) Right hip replacement.
nance imaging (MRI) of the head STAT for
a patient. Which data warrants immedi- The magnetic field generated by the MRI
ate intervention by the nurse concerning is so strong that metal-containing items are
this diagnostic test? strongly attracted to the magnet. Because
the hip joint is made of metal, a lead shield
A) Elevated blood pressure. must be used during the procedure. Elevated
B) Allergy to shell fish. blood pressure, an allergy to shell fish, and
C) Right hip replacement. a history of atrial fibrillation would not attect
D) History of atrial fibrillation. the MRI.
5. A client's daughter is sitting by her moth- B) "Your mother has had a stroke, and
er's bedside who was recently transferred the blood supply to the brain has been
to the Intermediate Care Unit. She states blocked."
"I don't understand what a brain attack
is. The healthcare provider told me my Rationale: The nurse can discuss what a di-
mother is in serious condition and they agnosis means. Nancy is unable to make
are going to run several tests. I just don't decisions, so the next of kin, her daughter,
know what is going on. What happened Gail, needs sufficient information to make in-
to my mother?" What is the best response formed decisions. The nurse has the knowl-
by the nurse? A) "I am sorry, but
according to the health
,HESI RN MEDICAL SURGICAL EXAM questions
well answered already passed (updated)
edge, and the responsibility, to explain Nan- cy's condition to Gail.
The nurse should give
, HESI RN MEDICAL SURGICAL EXAM questions
well answered already passed (updated)
Insurance Portability and Accounting Act facts first, and then address her feelings after
(HIPAA), I cannot give you any informa- the information is provided.
tion."
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 moth-
er's serious condition."
6. What is the normal range for cardiac out- The normal range for cardiac output to en-
put? sure cerebral blood flow and oxygen delivery
is 4 to 8 L/min.
7. A client was admitted with the diagno- Thrombolytic therapy is contraindicated in
sis of a brain attack. Their symptoms be- clients with symptom onset longer than 3
gan 24 hours before being admitted. Why hours prior to admission. This client had
would this client not be a candidate for symptoms for 24 hours before being brought
thrombolytic therapy? to the medical center
8. What are plate guards? Plate guards prevent food from being
pushed Ott the plate. Using plate guards and
other assistive devices will encourage inde-
pendence in a client with a self-care deficit.
9. Which condition is considered a
A) High cholesterol levels.
non-modifiable risk factor for a brain at-
B) Obesity.
tack?
