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HESI RN MEDICAL SURGICAL EXAM PACK 2025
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HESI RN MEDICAL SURGICAL EXAM PACK 2025 HESI RN MEDICAL SURGICAL EXAM PACK 2025 HESI RN MEDICAL SURGICAL EXAM PACK 2025
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HESI RN MEDICAL SURGICAL EXAMPACK 2025
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 - verified 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.
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. - verified 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.
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. - verified 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.
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. - verified 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.
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." - verified 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.
What is the normal range for cardiac output? - verified answer 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? - verified
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
What are plate guards? - verified 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.
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. - verified 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.
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. -
verified 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.
A physical therapist (PT) places a gait belt on a client and is assisting them with ambulation from the
bed to the chair. As they get up out of the bed, they report being dizzy and begin to fall. The PT
carefully allows them to fall back to the bed and notifies the primary nurse. Which written
documentation should the nurse put in the client's record?
A) Client experienced orthostatic hypotension when getting out of bed.
B) PT reported client complained of dizziness when getting out of bed, and gait belt was used to
allow client to fall back onto the bed.
C) PT notified the primary nurse that the client could not ambulate at this time because of dizziness.
D) Client had difficulty ambulating from the bed to the chair when accompanied by the PT, variance
report completed. - verified answer B) PT reported client complained of dizziness when getting out
of bed, and gait belt was used to allow client to fall back onto the bed.
Rationale: This documentation provides the factual data of the events that occurred. A)The nurse is
making an assumption that the dizziness was caused by orthostatic hypotension. C) Not all the
pertinent facts are included in this documentation.
D) A variance report should never be documented in the client's record.
A new nurse graduate is caring for a postoperative client with the following arterial blood gases
(ABGs): pH, 7.30; PCO2, 60 mm Hg; PO2, 80 mm Hg; bicarbonate, 24 mEq/L; and O2 saturation, 96%.
Which of these actions by the new graduate is indicated?
A) Encourage the client to use the incentive spirometer and to cough.
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