Hesi Exit Cat Exam 4, Questions & 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...
Hesi Exit Cat Exam 4, Questions & 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 - a
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
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. - B
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. - C
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." - B
What is the normal range for cardiac output? - 4-8L/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? -
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? - 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. - D
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. - B
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. - B
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. - A
The nurse is providing dietary instructions to a 68-year-old client who is at high risk for
development of coronary heart disease (CHD). Which information should the nurse include?
, A) Limit dietary selection of cholesterol to 300 mg per day
B) Increase intake of soluble fiber to 10 to 25 grams per day.
C) Decrease plant stanols and sterols to less than 2 grams/day.
D) Ensure saturated fat is less than 30% of total caloric intake. - B
A splint is prescribed for nighttime use by a client with rheumatoid arthritis. Which statement by
the nurse provides the most accurate explanation for use of the splints?
A) Prevention of deformities.
B) Avoidance of joint trauma.
C) Relief of joint inflammation.
D) Improvement in joint strength. - A
A 32-year-old female client complains of severe abdominal pain each month before her
menstrual period, painful intercourse, and painful defecation. Which additional history should
the nurse obtain that is consistent with the client's complaints?
A) Frequent urinary tract infections.
B) Inability to get pregnant.
C) Premenstrual syndrome.
D) Chronic use of laxatives. - B
A client with a 16-year history of diabetes mellitus is having renal function tests because of
recent fatigue, weakness, elevated blood urea nitrogen, and serum creatinine levels. Which
finding should the nurse conclude as an early symptom of renal insufficiency?
A) Dyspnea.
B) Nocturia.
C) Confusion.
D) Stomatitis. - B
A client with heart disease is on a continuous telemetry monitor and has developed sinus
bradycardia. In determining the possible cause of the bradycardia, the nurse assesses the client's
medication record. Which medication is most likely the cause of the bradycardia?
A) Propanolol (Inderal).
B) Captopril (Capoten).
C) Furosemide (Lasix).
D) Dobutamine (Dobutrex). - A
A client has been taking oral corticosteroids for the past five days because of seasonal allergies.
Which assessment finding is of most concern to the nurse?
A) White blood count of 10,000 mm3.
B) Serum glucose of 115 mg/dl.
C) Purulent sputum.
D) Excessive hunger. - C (indicates infection)
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