1 | Page
medsurg-hesi Questions and Answers
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
Ans: 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.
© 2025 All rights reserved
, 2 | Page
Ans: 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.
Ans: 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.
© 2025 All rights reserved
, 3 | Page
C) Right hip replacement.
D) History of atrial fibrillation.
Ans: 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."
Ans: 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?
© 2025 All rights reserved
, 4 | Page
Ans: 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?
Ans: 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?
Ans: 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.
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.
Ans: 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.
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.
© 2025 All rights reserved
medsurg-hesi Questions and Answers
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
Ans: 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.
© 2025 All rights reserved
, 2 | Page
Ans: 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.
Ans: 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.
© 2025 All rights reserved
, 3 | Page
C) Right hip replacement.
D) History of atrial fibrillation.
Ans: 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."
Ans: 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?
© 2025 All rights reserved
, 4 | Page
Ans: 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?
Ans: 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?
Ans: 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.
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.
Ans: 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.
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.
© 2025 All rights reserved
