HESI Medical Surgical Questions And Correct Detailed Answers (Verified Answers) Already Graded A+

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HESI Medical Surgical Questions And Correct Detailed Answers (Verified Answers) Already Graded A+

Nursing Assessment and Clinical Management Review

• A client is experiencing homonymous hemianopsia as the result of a brain attack.

Which nursing intervention would the nurse implement to address this condition?

• Turn Nancy every two hours and perform active range of motion exercises.
• Place the objects Nancy needs for activities of daily living on the left side of the table.
• Speak slowly and clearly to assist Nancy in forming sounds to words.
• Request that the dietary department thicken all liquids on Nancy's meal and snack

trays.Correct Answer: B) Place the objects Nancy needs for activities of daily living on the left side of the table.

• Which clinical manifestation further supports an assessment of a left-sided brain

attack?

• Visual field deficit on the left side.
• Spatial-perceptual deficits.
• Paresthesia of the left side.
• Global aphasia.

Correct Answer: D) Global aphasia.

• 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?

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• Client experienced orthostatic hypotension when getting out of bed.
• 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.

• PT notified the primary nurse that the client could not ambulate at this time because of

dizziness.

• Client had difficulty ambulating from the bed to the chair when accompanied by the PT,

variance report completed.Correct 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.

• When preparing a patient for a noncontrast computed tomography (CT) scan STAT,

what nursing intervention should the nurse implement?

• Determine if the client has any allergies to iodine
• Explain that the client will not be able to move her head throughout the CT scan.
• Premedicate the client to decrease pain prior to having the procedure.
• Provide an explanation of relaxation exercises prior to the procedure.

Correct Answer: B) Explain that the client will not be able to move her head throughout the CT scan.

• Which condition is considered a non-modifiable risk factor for a brain attack?
• High cholesterol levels.
• Obesity.
• History of atrial fibrillation.
• Advanced age.

Correct Answer: D) Advanced age.

• 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?

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• "I am sorry, but according to the Health Insurance Portability and Accounting Act

(HIPAA), I cannot give you any information."

• "Your mother has had a stroke, and the blood supply to the brain has been blocked."
• "How do you feel about what the healthcare provider said?"
• "I will call the healthcare provider so he/she can talk to you about your mother's serious

condition." Correct Answer: B) "Your mother has had a stroke, and the blood supply to the brain has been blocked."

• 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?

• Elevated blood pressure.
• Allergy to shell fish.
• Right hip replacement.
• History of atrial fibrillation.

Correct Answer: C) Right hip replacement.

• What are plate guards?

Correct 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.

• 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 carotid bruit
• A hypotensive blood pressure
• hyperreflexic deep tendon relexes.
• Decreased bowel sounds

Correct Answer: A) A carotid bruit.

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• What is the normal range for cardiac output?

Correct 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?Correct 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

• 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?

• Encourage the client to use the incentive spirometer and to cough.
• Administer oxygen by nasal cannula.
• Request a prescription for sodium bicarbonate from the health care provider.
• Inform the charge nurse that no changes in therapy are needed.

Correct Answer: A) Encourage the client to use the incentive spirometer and to cough.

• 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?

• Limit dietary selection of cholesterol to 300 mg per day
• Increase intake of soluble fiber to 10 to 25 grams per day.
• Decrease plant stanols and sterols to less than 2 grams/day.
• Ensure saturated fat is less than 30% of total caloric intake.

Correct Answer: B) Increase intake of soluble fiber to 10 to 25 grams per day.

• 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?

• Prevention of deformities.