medsurg-hesi exam latest complete update (100% pass guaranteed)
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 manifes...
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 - answers 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. - answers 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. - answers 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. - answers 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." - answers 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? - answers 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? - answers 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? - answers 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. - answers 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. - answers 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. - answers 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.
B) Administer oxygen by nasal cannula.
C) Request a prescription for sodium bicarbonate from the health care provider.
D) Inform the charge nurse that no changes in therapy are needed. - answers A)
Encourage the client to use the incentive spirometer and to cough.
Rationale: Respiratory acidosis is caused by CO2 retention and impaired chest
expansion secondary to anesthesia. The nurse takes steps to promote CO2 elimination,
including maintaining a patent airway and expanding the lungs through breathing
techniques. O2 is not indicated because Po2 and oxygen saturation are within the
normal range. Sodium bicarbonate is not indicated because the bicarbonate level is in
the normal range; promoting excretion of respiratory acids is the priority in respiratory
acidosis. Post anesthesia, the client will need interventions as described in A above or
may progress to a state of somnolence and unresponsiveness.
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