HESI RN FUNDAMENTALS QUESTIONS & ANSWERS
1. When caring for a patient with a new right-sided homonymous hemianopsia resulting from a stroke,
which
... [Show More] intervention should the nurse include in the plan of care?
a. Apply an eye patch to the right eye.
b. Approach the patient from the right side.
c. Place needed objects on the patient’s left side.
d.Teach the patient that the left visual deficit will
resolve. ANS: C
During the acute period, the nurse should place objects on the patient’s unaffected side. Because there is
a visual defect in the right half of each eye, an eye patch is not appropriate. The patient should be
approached from the left side. The visual deficit may not resolve, although the patient can learn to
compensate for the defect.
2. A left-handed patient with left-sided hemiplegia has difficulty feeding himself. Which intervention
should the nurse include in the plan of care?
a. Provide a wide variety of food choices.
b. Provide oral care before and after meals.
c. Assist the patient to eat with the right hand.
d. Teach the patient the “chin-tuck”
technique. ANS: C
Because the patient has difficulty feeding himself, the appropriate interventions will focus on teaching
the patient to use the right hand for self-feeding. The other interventions are appropriate for patients
with other etiologies for the imbalanced nutrition.
3. A patient has a ruptured cerebral aneurysm and subarachnoid hemorrhage. Which intervention will
the nurse include in the plan of care?
a. Apply intermittent pneumatic compression stockings.
b. Assist to dangle on edge of bed and assess for dizziness.
c. Encourage patient to cough and deep breathe every 4 hours. d. Insert an oropharyngeal airway to
prevent airway obstruction.
ANS: A
The patient with a subarachnoid hemorrhage usually has minimal activity to prevent cerebral vasospasm
or further bleeding and is at risk for venous thromboembolism. Activities such as coughing and sitting
up that might increase intracranial pressure or decrease cerebral blood flow are avoided. Because there is
no indication that the patient is unconscious, an oropharyngeal airway is inappropriate.
4. A patient will attempt oral feedings for the first time after having a stroke. The nurse should assess the
gag reflex and then
a. order a varied pureed diet. c. assist the patient into a chair.
b. assess the patient’s appetite. d. offer the patient a sip of
juice. ANS: C
The patient should be as upright as possible before attempting feeding to make swallowing easier and
decrease aspiration risk. To assess swallowing ability, the nurse should initially offer water or ice to the
patient. Pureed diets are not recommended because the texture is too smooth. The patient may have a
poor appetite, but the oral feeding should be attempted.
5. A male patient who has right-sided weakness after a stroke is making prog [Show Less]