HESI RN MEDICAL SURGICAL EXAM PACK 2024 QUESTIONS AND ANSWERS GRADED A
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Course
HESI RN MEDICAL SURGICAL
Institution
HESI RN MEDICAL SURGICAL
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 att...
HESI RN MEDICAL SURGICAL EXAM
PACK 2024 QUESTIONS AND ANSWERS
GRADED A
An ER nurse is completing an Which clinical manifestation further
assessment on a patient that is alert supports an assessment of a left-sided
but struggles to answer questions. brain attack?
When she attempts to talk, she slurs
her speech and appears very
frightened. What additional clinical A) Visual field deficit on the left side.
manifestation does the nurse expect to B) Spatial-perceptual deficits.
find if nacy's sysmptoms have been
caused by a brain attack (stroke)? C) Paresthesia of the left side.
D) Global aphasia.
A. A carotid bruit D) Global aphasia. - D) Global aphasia.
B. A hypotensive blood pressure
C. hyperreflexic deep tendon relexes. Rationale: Global aphasia refers to
difficulty speaking, listening, and
D. Decreased bowel sounds - A) A understanding, as well as difficulty
carotid bruit. reading and writing. Symptoms vary
from person to person. Aphasia may
occur secondary to any brain injury
Rationale: the carotid artery (artery to
involving the left hemisphere. Visual
the brain) is narrowed in clients with a
field deficits, spatial-perceptual
brain attack. A bruit is an abnormal
deficits, and paresthsia of the left side
sound heard on auscultation resulting
usually occur with right-sided brain
from interference with normal blood
attack.
flow. Usually the blood pressure is
hypertensive. Initially flaccid paralysis
occurs, resulting in hyporefkexic deep When preparing a patient for a
tendon reflexes. Bowel sounds are not noncontrast computed tomography
indicative of a brain attack. (CT) scan STAT, what nursing
intervention should the nurse
implement?
, HESI RN MEDICAL SURGICAL EXAM
PACK 2024 QUESTIONS AND ANSWERS
GRADED A
A neurologist prescribes a magnetic
resonance imaging (MRI) of the head
A) Determine if the client has any
STAT for a patient. Which data warrants
allergies to iodine
immediate intervention by the nurse
B) Explain that the client will not be concerning this diagnostic test?
able to move her head throughout the
CT scan.
A) Elevated blood pressure.
C) Premedicate the client to decrease
pain prior to having the procedure. B) Allergy to shell fish.
D) Provide an explanation of relaxation C) Right hip replacement.
exercises prior to the procedure. - B)
D) History of atrial fibrillation. - C)
Explain that the client will not be able
Right hip replacement.
to move her head throughout the CT
scan.
The magnetic field generated by the
MRI is so strong that metal-containing
Rationale: Because head motion will
items are strongly attracted to the
distort the images, Nancy will have to
magnet. Because the hip joint is made
remain still throughout the procedure.
of metal, a lead shield must be used
Allergies to iodine is important if
during the procedure. Elevated blood
contrast dye is being used for the CT
pressure, an allergy to shell fish, and a
scan. Premedicating the client to
history of atrial fibrillation would not
decrease pain prior to the procedure is
affect the MRI.
unnecessary because CT scanning is a
noninvasive and painless procedure.
Providing an explanation of relaxation A client's daughter is sitting by her
exercises prior to the procedure is a mother's bedside who was recently
worthwhile intervention to decrease transferred to the Intermediate Care
anxiety but is not of highest priority. Unit. She states "I don't understand
what a brain attack is. The healthcare
provider told me my mother is in
, HESI RN MEDICAL SURGICAL EXAM
PACK 2024 QUESTIONS AND ANSWERS
GRADED A
serious condition and they are going to explain Nancy's condition to Gail. The
run several tests. I just don't know nurse should give facts first, and then
what is going on. What happened to my address her feelings after the
mother?" What is the best response by information is provided.
the nurse?
What is the normal range for cardiac
A) "I am sorry, but according to the output? - The normal range for cardiac
Health Insurance Portability and output to ensure cerebral blood flow
Accounting Act (HIPAA), I cannot give and oxygen delivery is 4 to 8 L/min.
you any information."
B) "Your mother has had a stroke, and
A client was admitted with the
the blood supply to the brain has been
diagnosis of a brain attack. Their
blocked."
symptoms began 24 hours before
C) "How do you feel about what the being admitted. Why would this client
healthcare provider said?" not be a candidate for for thrombolytic
therapy? - Thrombolytic therapy is
D) "I will call the healthcare provider so
contraindicated in clients with
he/she can talk to you about your
symptom onset longer than 3 hours
mother's serious condition." - B) "Your
prior to admission. This client had
mother has had a stroke, and the blood
symptoms for 24 hours before being
supply to the brain has been blocked."
brought to the medical center
Rationale: The nurse can discuss what
What are plate guards? - Plate guards
a diagnosis means. Nancy is unable to
prevent food from being pushed off the
make decisions, so the next of kin, her
plate. Using plate guards and other
daughter, Gail, needs sufficient
assistive devices will encourage
information to make informed
independence in a client with a self-
decisions. The nurse has the
care deficit.
knowledge, and the responsibility, to
, HESI RN MEDICAL SURGICAL EXAM
PACK 2024 QUESTIONS AND ANSWERS
GRADED A
A) Turn Nancy every two hours and
perform active range of motion
Which condition is considered a non-
exercises.
modifiable risk factor for a brain
attack? B) Place the objects Nancy needs for
activities of daily living on the left side
of the table.
A) High cholesterol levels.
C) Speak slowly and clearly to assist
B) Obesity. Nancy in forming sounds to words.
C) History of atrial fibrillation. D) Request that the dietary
D) Advanced age. - D) Advanced age. department thicken all liquids on
Nancy's meal and snack trays. - B)
Place the objects Nancy needs for
Rationale: People over age 55 are a activities of daily living on the left side
high-risk group for a brain attack of the table.
because the incidence of stroke more
than doubles in each successive
decade of life. Non-modifiable means Rationale: Homonymous hemianopsia
the client cannot do anything to is loss of the visual field on the same
change the risk factor. All the other side as the paralyzed side. This results
options are modifiable risk factors. in the client neglecting that side of the
body, so it is beneficial to place
objects on that side. Nancy had a left-
A client is experiencing homonymous hemisphere brain attack so her right
hemianopsia as the result of a brain side is the weak side. Speaking slowly
attack. Which nursing intervention and clearly would address the client's
would the nurse implement to address verbal deficits due to aphasia.
this condition? Requesting all liquids to be thickened
would address dysphagia. Turning the
client every 2 hours and performing
active range of motion exercises would
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