CHAPTER #45 (MEDICAL SURGICAL
NURSING) QUESTIONS WITH ANSWERS.
The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain
attack). Which characteristics are associated with this condition? Select all that apply.
A. The client is aphasic.
B. The client has weakness on the right side of the body.
C. The client has complete bilateral paralysis of the arms and legs.
D. The client has weakness on the right side of the face and tongue.
E. The client has lost the ability to move the right arm but is able to walk independently.
F. The client has lost the ability to ambulate independently but is able to feed and bathe himself or
herself without assistance. ANSWER :-A. The client is aphasic.
B. The client has weakness on the right side of the body.
D. The client has weakness on the right side of the face and tongue.
hemiparesis is weakness of one side of the body that may occur after a stroke involving weakness of the
face and tongue, arm, and leg on one side which requires assistance with feeding, bathing, & ambulating
complete bilateral paralysis does not occur in hemiparesis
The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend
in vital signs if the intracranial pressure is rising?
A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure
B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure
C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure
D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure
ANSWER :-B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood
pressure
,A client with a neurological problem is experiencing hyperthermia. Which measures would be
appropriate for the nurse to use in trying to lower the client's body temperature? Select all that apply.
A. Giving tepid sponge baths
B. Applying a hypothermia blanket
C. Covering the client with blankets
D. Administering acetaminophen per protocol
E. Placing ice packs over the client's abdomen and in the axilla and groin ANSWER :-A. Giving tepid
sponge baths
B. Applying a hypothermia blanket
D. Administering acetaminophen per protocol
standard measures to lower body temperature include removing bed covers, providing cool sponge
baths, using an electric fan in the room, administering acetaminophen, and placing a hypothermia
blanket under the patient
ice packs could cause shivering which increases cellular oxygen demands and has the potential to
increase ICP
A patient with a TBI has nonreactive and dilated pupils. What would the nurse anticipate?
A. Loss of vision
B. Brain stem herniation
C. Intense headache
D. Projectile vomiting ANSWER :-B. Brain stem herniation
The nurse understands which symptom is the earliest indicator of increased intracranial pressure when
caring for a patient with a head injury?
A. Increased pupil size
B. Nausea and vomiting
, C. Agitation and confusion
D. Elevated blood pressure ANSWER :-C. Agitation and confusion
CASE STUDY: The spouse of a patient brought to the ED states that 6 hours ago her husband began
having difficulty finding words. The patient has since become progressively worse. He has right
hemiparesis. Upon assessing the patient, you note that he is lying flat in a supine position and has been
incontinent of urine. What is the priority nursing intervention for this patient at this time?
A. Provide perineal care.
B. Assess for gag reflex.
C. Elevate the head of the bed.
D. Perform a linen and gown change. ANSWER :-C. Elevate the head of the bed.
An hour later after a CT scan, the patient is diagnosed with a left hemisphere stroke. Which
manifestations would the nurse expect? Select all that apply.
A. Constant smiling
B. Intellectual impairment
C. Deficits in the right visual field
D. Disorientation to time, place, and person
E. Inability to discriminate words and letters ANSWER :-B. Intellectual impairment
C. Deficits in the right visual field
E. Inability to discriminate words and letters
patients experiencing a left hemisphere stroke display an inability to discriminate words and letters,
intellectual impairment, and deficits in the right visual field.
disorientation, constant smiling, and neglect of left visual field are manifestations of a right hemisphere
stroke
NURSING) QUESTIONS WITH ANSWERS.
The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain
attack). Which characteristics are associated with this condition? Select all that apply.
A. The client is aphasic.
B. The client has weakness on the right side of the body.
C. The client has complete bilateral paralysis of the arms and legs.
D. The client has weakness on the right side of the face and tongue.
E. The client has lost the ability to move the right arm but is able to walk independently.
F. The client has lost the ability to ambulate independently but is able to feed and bathe himself or
herself without assistance. ANSWER :-A. The client is aphasic.
B. The client has weakness on the right side of the body.
D. The client has weakness on the right side of the face and tongue.
hemiparesis is weakness of one side of the body that may occur after a stroke involving weakness of the
face and tongue, arm, and leg on one side which requires assistance with feeding, bathing, & ambulating
complete bilateral paralysis does not occur in hemiparesis
The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend
in vital signs if the intracranial pressure is rising?
A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure
B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure
C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure
D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure
ANSWER :-B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood
pressure
,A client with a neurological problem is experiencing hyperthermia. Which measures would be
appropriate for the nurse to use in trying to lower the client's body temperature? Select all that apply.
A. Giving tepid sponge baths
B. Applying a hypothermia blanket
C. Covering the client with blankets
D. Administering acetaminophen per protocol
E. Placing ice packs over the client's abdomen and in the axilla and groin ANSWER :-A. Giving tepid
sponge baths
B. Applying a hypothermia blanket
D. Administering acetaminophen per protocol
standard measures to lower body temperature include removing bed covers, providing cool sponge
baths, using an electric fan in the room, administering acetaminophen, and placing a hypothermia
blanket under the patient
ice packs could cause shivering which increases cellular oxygen demands and has the potential to
increase ICP
A patient with a TBI has nonreactive and dilated pupils. What would the nurse anticipate?
A. Loss of vision
B. Brain stem herniation
C. Intense headache
D. Projectile vomiting ANSWER :-B. Brain stem herniation
The nurse understands which symptom is the earliest indicator of increased intracranial pressure when
caring for a patient with a head injury?
A. Increased pupil size
B. Nausea and vomiting
, C. Agitation and confusion
D. Elevated blood pressure ANSWER :-C. Agitation and confusion
CASE STUDY: The spouse of a patient brought to the ED states that 6 hours ago her husband began
having difficulty finding words. The patient has since become progressively worse. He has right
hemiparesis. Upon assessing the patient, you note that he is lying flat in a supine position and has been
incontinent of urine. What is the priority nursing intervention for this patient at this time?
A. Provide perineal care.
B. Assess for gag reflex.
C. Elevate the head of the bed.
D. Perform a linen and gown change. ANSWER :-C. Elevate the head of the bed.
An hour later after a CT scan, the patient is diagnosed with a left hemisphere stroke. Which
manifestations would the nurse expect? Select all that apply.
A. Constant smiling
B. Intellectual impairment
C. Deficits in the right visual field
D. Disorientation to time, place, and person
E. Inability to discriminate words and letters ANSWER :-B. Intellectual impairment
C. Deficits in the right visual field
E. Inability to discriminate words and letters
patients experiencing a left hemisphere stroke display an inability to discriminate words and letters,
intellectual impairment, and deficits in the right visual field.
disorientation, constant smiling, and neglect of left visual field are manifestations of a right hemisphere
stroke
