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HESI RN MEDICAL SURGICAL EXAM PACK 2024 QUESTIONS AND 100% SURE ANSWERS
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HESI RN MEDICAL SURGICAL EXAM PACK 2024 QUESTIONS AND 100% SURE ANSWERS
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JACKLINEHESI RN MEDICAL SURGICAL EXAM PACK 2024
QUESTIONS AND 100% SURE ANSWERS
Terms in this set (230)
An ER nurse is completing an assessment on a A) A carotid bruit.
patient that is alert but struggles to answer
questions. When she attempts to talk, she slurs her Rationale: the carotid artery (artery to the brain) is narrowed in clients with a brain attack. A bruit
speech and appears very frightened. What is an abnormal sound heard on auscultation resulting from interference with normal blood flow.
additional clinical manifestation does the nurse Usually the blood pressure is hypertensive. Initially flaccid paralysis occurs, resulting in
expect to find if nacy's sysmptoms have been hyporefkexic deep tendon reflexes. Bowel sounds are not indicative of a brain attack.
caused by a brain attack (stroke)?
A. A carotid bruit
B. A hypotensive blood pressure
C. hyperreflexic deep tendon relexes.
D. Decreased bowel sounds
HESI RN MEDICAL SURGICAL EXAM PACK 2024 QUESTIONS AND ANSWERS
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,Which clinical manifestation further supports an D) Global aphasia.
assessment of a left-sided brain attack?
Rationale: Global aphasia refers to difficulty speaking, listening, and understanding, as well as
A) Visual field deficit on the left side. difficulty reading and writing. Symptoms vary from person to person. Aphasia may occur
B) Spatial-perceptual deficits. secondary to any brain injury involving the left hemisphere. Visual field deficits, spatial-perceptual
C) Paresthesia of the left side. deficits, and paresthsia of the left side usually occur with right-sided brain attack.
D) Global aphasia.
D) Global aphasia.
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When preparing a patient for a noncontrast B) Explain that the client will not be able to move her head throughout the CT scan.
computed tomography (CT) scan STAT, what
nursing intervention should the nurse implement? 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.
A) Determine if the client has any allergies to Premedicating the client to decrease pain prior to the procedure is unnecessary because CT
iodine scanning is a noninvasive and painless procedure. Providing an explanation of relaxation
B) Explain that the client will not be able to move exercises prior to the procedure is a worthwhile intervention to decrease anxiety but is not of
her head throughout the CT scan. highest priority.
C) Premedicate the client to decrease pain prior
to having the procedure.
D) Provide an explanation of relaxation exercises
prior to the procedure.
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A neurologist prescribes a magnetic resonance C) Right hip replacement.
imaging (MRI) of the head STAT for a patient.
Which data warrants immediate intervention by The magnetic field generated by the MRI is so strong that metal-containing items are strongly
the nurse concerning this diagnostic test? 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
A) Elevated blood pressure. fibrillation would not affect the MRI.
B) Allergy to shell fish.
C) Right hip replacement.
D) History of atrial fibrillation.
HESI RN MEDICAL SURGICAL EXAM PACK 2024 QUESTIONS AND ANSWERS
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,8/31/24, 1:25 PM
A client's daughter is sitting by her mother's B) "Your mother has had a stroke, and the blood supply to the brain has been blocked."
bedside who was recently transferred to the
Intermediate Care Unit. She states "I don't Rationale: The nurse can discuss what a diagnosis means. Nancy is unable to make decisions, so
understand what a brain attack is. The healthcare the next of kin, her daughter, Gail, needs sufficient information to make informed decisions. The
provider told me my mother is in serious condition nurse has the knowledge, and the responsibility, to explain Nancy's condition to Gail. The nurse
and they are going to run several tests. I just don't should give facts first, and then address her feelings after the information is provided.
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."
The normal range for cardiac output to ensure cerebral blood flow and oxygen delivery is 4 to 8
What is the normal range for cardiac output?
L/min.
A client was admitted with the diagnosis of a brain Thrombolytic therapy is contraindicated in clients with symptom onset longer than 3 hours prior
attack. Their symptoms began 24 hours before to admission. This client had symptoms for 24 hours before being brought to the medical center
being admitted. Why would this client not be a
candidate for for thrombolytic therapy?
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Plate guards prevent food from being pushed off the plate. Using plate guards and other
What are plate guards?
assistive devices will encourage independence in a client with a self-care deficit.
Which condition is considered a non-modifiable D) Advanced age.
risk factor for a brain attack?
Rationale: People over age 55 are a high-risk group for a brain attack because the incidence of
A) High cholesterol levels. stroke more than doubles in each successive decade of life. Non-modifiable means the client
B) Obesity. cannot do anything to change the risk factor. All the other options are modifiable risk factors.
C) History of atrial fibrillation.
D) Advanced age.
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HESI RN MEDICAL SURGICAL EXAM PACK 2024 QUESTIONS AND ANSWERS
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, 8/31/24, 1:25 PM
A client is experiencing homonymous B) Place the objects Nancy needs for activities of daily living on the left side of the table.
hemianopsia as the result of a brain attack. Which
nursing intervention would the nurse implement to Rationale: Homonymous hemianopsia is loss of the visual field on the same side as the paralyzed
address this condition? 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
A) Turn Nancy every two hours and perform active slowly and clearly would address the client's verbal deficits due to aphasia. Requesting all liquids
range of motion exercises. to be thickened would address dysphagia. Turning the client every 2 hours and performing active
B) Place the objects Nancy needs for activities of range of motion exercises would address the client's risk for immobility due to paralysis.
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.
A physical therapist (PT) places a gait belt on a B) PT reported client complained of dizziness when getting out of bed, and gait belt was used to
client and is assisting them with ambulation from allow client to fall back onto the bed.
the bed to the chair. As they get up out of the
bed, they report being dizzy and begin to fall. The Rationale: This documentation provides the factual data of the events that occurred. A)The nurse
PT carefully allows them to fall back to the bed is making an assumption that the dizziness was caused by orthostatic hypotension. C) Not all the
and notifies the primary nurse. Which written pertinent facts are included in this documentation.
documentation should the nurse put in the client's D) A variance report should never be documented in the client's record.
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.
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