MEDSURG-HESI EXAM
1. 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 client's symptoms have been
caused by a brain attack (stroke)?
A. A carotid bruit
B. A hypotensive blood pressure
C. hyperreflexia deep tendon reflexes.
D. Decreased bowel sounds
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 hyporeflexia deep tendon
reflexes. Bowel sounds are not indicative of a brain attack.
2. 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.
E) Global aphasia.
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 paresthesia of
the left side usually occur with right-sided brain attack.
3. When preparing a patient for a noncontract 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.
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
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,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.
4. 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.
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.
5. 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."
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.
6. What is the normal range for cardiac output?
ANSWER: The normal range for cardiac output to ensure cerebral blood flow and oxygen delivery is 4 to
8 L/min.
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, 7. 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 thrombolytic therapy? -
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?
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.
8. 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.
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.
9. 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.
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.
10. 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.
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