HESI MS HESI Medical and Surgical Exam - Set 4 - Part 2

Correct Answer: Decerebrate posturing, indicating a lesion at the level of the brainstem.

Decerebrate posturing — rigid extension of the arms with pronation of the wrists and extension of the legs — indicates a brainstem lesion, specifically dysfunction at or below the midbrain. This pattern represents a significant neurological deterioration and is an ominous finding requiring urgent reassessment and provider notification. Option a is incorrect because decorticate posturing produces flexion of one or both arms toward the chest, not the rigid bilateral arm extension seen here. Decorticate posturing indicates cortical dysfunction and is a less severe finding than the brainstem-level lesion identified by the decerebrate pattern. Option b is incorrect because flaccid posturing is the complete absence of motor response to any stimulus in all four extremities. The client here is producing a motor response — just an abnormal extension pattern — which is distinct from the total motor silence of flaccid posturing. Option c is incorrect because opisthotonus is hyperextension of the

Correct Answer: Apply a loose dry sterile dressing over the ear and notify the provider without attempting to clean the canal.

Confirmed CSF leakage from the ear requires a loose, dry, non-obstructing sterile dressing that allows drainage to continue while protecting the site from contamination. The provider must be notified immediately. The ear canal is never suctioned, packed, or irrigated, as these actions introduce infection risk or obstruct intracranial pressure equilibration. Option b is incorrect because suctioning the ear canal forces negative pressure against the CSF leak and creates a direct pathway for oral flora to enter the subarachnoid space. Introducing bacteria into the CSF through a basilar skull fracture is one of the primary risks of meningitis in this injury. Option c is incorrect because packing the ear canal blocks the natural drainage pathway and traps CSF against a hole in the skull, which can cause intracranial pressure to rise. Only a loose, non-compressive dressing is appropriate to protect the site without obstructing drainage. Option d is incorrect because tilting the head to promo

Correct Answer: Maintain a consistent calm routine, limit room changes, and place familiar objects from home at the bedside.

Clients with Alzheimer's disease depend on environmental consistency and familiar cues to reduce anxiety and behavioral disturbances. A predictable routine, familiar personal objects, and calm unhurried communication compensate for memory deficits and minimize the disorientation that triggers agitation. Option a is incorrect because forcefully reorienting a client with Alzheimer's disease causes distress without producing lasting orientation. The client cannot retain new information, so corrections about the date or a family member's death are experienced repeatedly as fresh grief and confusion, worsening agitation. Option b is incorrect because dim lighting reduces the environmental cues the client needs to maintain situational awareness, increasing disorientation. Family visitors often provide comfort and behavioral grounding for Alzheimer's clients; restricting them typically worsens agitation rather than reducing it. Option d is incorrect because clients with mo

Correct Answer: Loss of sympathetic vascular tone below the injury causes vasodilation and hypotension without the ability to compensate with tachycardia.

In cervical spinal cord injury, the disruption of descending sympathetic pathways leaves peripheral blood vessels below the lesion permanently dilated. Blood pools in the periphery, reducing venous return and blood pressure. The injured cord also prevents the compensatory tachycardia that an intact autonomic system would generate in response to hypotension. Option a is incorrect because internal hemorrhage produces cool, clammy, pale skin and tachycardia from sympathetic activation — the opposite of the warm skin and bradycardia seen in this client. Hemorrhage eight weeks after an SCI is also an unlikely acute finding without a precipitating event. Option b is incorrect because fluid loss from a urinary tract infection does not produce the specific pattern of warm skin below the injury with hypotension and bradycardia. Fluid deficit from infection causes tachycardia and general pallor, not the vasodilated warmth seen in neurogenic hypotension. Option c is incorrect because septic shock

Correct Answer: Withhold anticholinesterase medication and prepare to administer atropine sulfate.

Cholinergic crisis results from anticholinesterase overdose, flooding the neuromuscular junction with acetylcholine. The immediate treatment is to withhold the offending drug and administer atropine sulfate, which blocks the excess muscarinic cholinergic effects and protects airway secretions from overwhelming the client. Option a is incorrect because increasing pyridostigmine in a client who is already experiencing anticholinesterase toxicity would add more of the same mechanism of injury. The neuromuscular junctions are already saturated with acetylcholine; giving more drug that blocks its breakdown would worsen the crisis and risk respiratory failure. Option c is incorrect because administering edrophonium to a client in cholinergic crisis adds more anticholinesterase activity to an already toxic state. Edrophonium in this situation worsens weakness and can trigger laryngospasm, bronchospasm, or cardiac arrest. The history of double dosing makes the diagnosis sufficiently clear with

Correct Answer: Use a bed cradle to keep sheets off the feet and perform passive range-of-motion exercises on the lower extremities.

A bed cradle removes the triggering mechanical stimulus of sheet pressure on hypersensitive extremities while passive range-of-motion exercises prevent contractures, deep vein thrombosis, and pressure injury from the immobility. Both interventions address active problems simultaneously without creating additional risks. Option b is incorrect because warm compresses may exacerbate the burning pain from GBS-related hypersensitivity, and reducing lower extremity assessments to once per shift is unsafe for a client with ascending paralysis who requires frequent monitoring for respiratory deterioration and neurovascular changes. Option c is incorrect because strict supine immobility without range-of-motion activity produces serious complications including contractures, venous thrombosis, and pressure injuries. Pain management is appropriate but must be paired with mobility interventions, not substituted for them. Option d is incorrect because applying sequential compression devices to a cli

Correct Answer: ALS selectively destroys motor neurons while leaving the sensory system, cognitive function, and autonomic control intact throughout the disease course.

ALS is a disease of the motor neuron system — upper and lower motor neurons — that relentlessly destroys voluntary movement while preserving sensation, intellect, and autonomic function. Clients retain full awareness of their progressive paralysis, can feel touch and pain normally, and maintain bowel and bladder sensation until very late in the disease. Option a is incorrect because ALS does not damage the sensory nervous system. Ascending numbness and tingling from the feet upward is the pattern seen in Guillain-Barré syndrome and peripheral neuropathy. In ALS, the sensory pathways are structurally intact and clients continue to feel pain, temperature, and touch normally throughout their illness. Option b is incorrect because cognitive decline and bladder incontinence are not typical features of ALS. Dementia is characteristic of Alzheimer's disease and other primary dementias; bladder dysfunction is seen in multiple sclerosis and spinal cord injury. ALS spares these systems, and

Correct Answer: Phenytoin causes gingival hyperplasia, characterized by reddened, swollen, easily bleeding gums.

Gingival hyperplasia is a well-documented adverse effect of phenytoin that results in reddened, swollen gum tissue that bleeds easily. Meticulous oral hygiene and regular dental cleanings reduce its severity. The client should report significant gum changes to the provider, who may adjust the medication or refer to dentistry. Option a is incorrect because dry mouth and dental caries are not the primary oral adverse effect attributed to phenytoin. While any medication that reduces saliva flow can affect dental health indirectly, gingival hyperplasia is the specific, well-documented phenytoin effect that requires targeted oral hygiene education. Option b is incorrect because phenytoin does not cause oral candidiasis. Candidiasis is an opportunistic fungal infection associated with immunosuppression, inhaled corticosteroids, or disrupted oral flora from antibiotics — not with the anticonvulsant mechanism of phenytoin. Option d is incorrect because leukoplakia is a potentially precancerous

Correct Answer: These findings indicate compartment syndrome requiring immediate provider notification and possible fasciotomy.

Pain unrelieved by analgesics, paresthesia, discoloration, and prolonged capillary refill distal to a cast are the cardinal signs of compartment syndrome. Neurovascular damage becomes irreversible without decompression within four to six hours; the provider must be notified immediately and fasciotomy or cast bivalving considered. Option b is incorrect because post-casting edema does not cause bluish discoloration, a six-second capillary refill, and pain that opioids cannot relieve. These findings indicate vascular and neural compromise from rising compartment pressure, not benign swelling that position alone will resolve. Option c is incorrect because deep vein thrombosis presents with calf swelling, warmth, redness, and tenderness along the venous path, not with acute bilateral-toe ischemia and unresponsive pain. DVT causes sluggish venous return; compartment syndrome causes arterial compression and tissue ischemia. Option d is incorrect because plaster does not stain the skin blue th

Correct Answer: Plaster dries in 24 to 72 hours; handle with the palms only during drying; use only the cool setting on a hair dryer.

Plaster casts require 24 to 72 hours to fully cure. During this period, the cast must be handled with the flat palms to prevent fingerprint indentations that create internal pressure points. A hair dryer may be used only on the cool setting, as heat causes the plaster to warm and can burn the underlying skin. Option a is incorrect because the 20-minute drying time applies to fiberglass synthetic casts, not plaster. Using a hair dryer on a warm or hot setting heats the plaster and burns the skin underneath, and gripping the wet cast with fingertips leaves permanent indentations that cause sustained pressure injuries. Option b is incorrect because plaster drying takes much longer than 8 hours and wrapping the cast in a towel traps moisture, delays drying, and weakens the structural integrity of the cast. The cast needs open air circulation, not insulation, during the curing period. Option c is incorrect because the 24 to 48-hour range is too short; plaster may require up to 72 hours to f

Correct Answer: Rewrap the residual limb immediately with an elastic compression bandage.

When the compression bandage slips off an amputated residual limb, the nurse must rewrap it immediately. Edema develops rapidly once compression is lost and will delay prosthetic fitting and rehabilitation. Rewrapping an amputated residual limb is a nursing action within scope that does not require a new provider order when the original order exists. Option a is incorrect because ice has limited effectiveness against the rapid edema that forms when circumferential compression is removed from an amputated limb. Ice alone does not prevent the degree of swelling that interrupts prosthetic fitting timelines; only restored compression achieves that goal. Option c is incorrect because waiting for a provider order before rewrapping allows significant edema to develop over the minutes to hours required to reach the provider. Rewrapping is a routine nursing measure for an existing post-amputation order, not a new intervention requiring fresh authorization. Option d is incorrect because elevatin

Correct Answer: Move the left foot up first onto the next step, then bring both crutches and the right foot up.

When ascending stairs with crutches, the unaffected leg leads because it provides the power to push the body upward. Once the left foot is planted on the higher step, both crutches and the affected right foot follow together, allowing the strong left leg to complete the lift from a stable base. Option a is incorrect because leading with the non-weight-bearing right foot and crutches forces the left leg to push from below without a planted foot on the higher step, creating an unstable and dangerous configuration on the ascending stair. Option b is incorrect because advancing both crutches independently without either foot on the new step leaves the client momentarily balanced only on the crutch tips, which is an unstable tripod position on a step edge. A controlled alternating sequence is required for stair safety. Option d is incorrect because placing the affected non-weight-bearing right foot up first requires bearing weight on it during the step-up, which is prohibited. The unaffecte

Correct Answer: Methotrexate is a DMARD that slows joint destruction; combining it with NSAIDs like ibuprofen raises the risk of hepatotoxicity and gastrointestinal bleeding and requires provider evaluation.

Methotrexate is a disease-modifying antirheumatic drug that slows joint destruction through antiproliferative and immune-modulating mechanisms. NSAIDs such as ibuprofen reduce its renal excretion, raising plasma methotrexate concentrations and increasing the risk of hepatotoxicity and gastrointestinal toxicity. The provider must evaluate whether concurrent use is appropriate. Option b is incorrect because methotrexate is not an NSAID; it belongs to the DMARD class with a completely different mechanism involving folate antagonism and immune modulation. While both reduce inflammation, they act through entirely different pathways and drug interaction risks cannot be dismissed by comparing class membership. Option c is incorrect because methotrexate is not a corticosteroid and the combination is not universally safe. Methotrexate is specifically a disease-modifying agent with hepatotoxic potential, and the interaction with ibuprofen requires careful monitoring for toxicity rather than assu

Correct Answer: Provide bed rest with the joint elevated and a low-purine diet with fluid intake of at least 2000 mL per day.

During an acute gout attack, bed rest reduces mechanical stress on the inflamed joint and elevation decreases edema. A low-purine diet limits uric acid production by avoiding organ meats, alcohol, and aged cheeses, and high fluid intake promotes uric acid excretion and reduces the risk of urate kidney stones. Option a is incorrect because unrestricted ambulation during an acute gout attack forces weight bearing on a severely inflamed metatarsophalangeal joint, dramatically worsening pain and potentially causing additional urate crystal deposition. High-protein intake also raises uric acid levels and is contraindicated during a gout attack. Option b is incorrect because dependent positioning increases venous congestion and edema in an already inflamed joint. Restricting fluids is the opposite of correct management; concentrated urine promotes renal urate stone formation and reduces the body's ability to excrete the excess uric acid driving the attack. Option c is incorrect because

Correct Answer: Administer prescribed IV antibiotics, maintain strict wound asepsis, monitor CBC and renal function regularly, and assess for signs of sepsis.

Osteomyelitis requires aggressive long-term IV antibiotic therapy because oral routes do not reliably achieve therapeutic bone concentrations. Strict wound asepsis prevents secondary infection, and monitoring CBC and renal function tracks treatment response and detects antibiotic nephrotoxicity. Assessment for systemic sepsis remains essential throughout. Option a is incorrect because oral antibiotics do not achieve sufficient bone tissue concentrations to eradicate osteomyelitis reliably, particularly with MRSA. Full weight bearing on an infected, structurally weakened femur risks pathological fracture through bone that is undergoing inflammatory destruction. Option c is incorrect because topical antibiotic cream does not penetrate bone tissue and has no role in treating a deep bone infection. Fluid restriction interferes with renal excretion of antibiotics and toxins. Amputation is reserved for unrelenting infection after maximal medical and surgical management has failed. Option d i

Correct Answer: Hold the cane in the right hand on the unaffected side, advancing the cane with each step of the affected left leg.

The cane is held in the hand opposite the affected extremity so that when the client steps forward with the weak left leg, the cane advances at the same time, creating a three-point support that shifts weight away from the compromised knee. Moving the cane on the unaffected side creates the correct biomechanical counterbalance. Option a is incorrect because a cane on the affected side creates the same base of support as the weak leg, providing no offloading benefit. The mechanical advantage of a cane depends on placing it on the opposite side, which extends the support base and diverts compressive forces away from the surgical joint. Option b is incorrect because alternating hands destroys the coordinated cane-and-affected-leg movement pattern that provides gait stability. Consistent use on the unaffected side maintains the three-point contact cadence throughout every stride. Option d is incorrect because cane placement is not a comfort preference with an equally correct alternative; i

Correct Answer: Take alendronate first thing in the morning before any food or drink with a full glass of plain water, then remain upright for at least 30 minutes.

Bisphosphonates must be taken in the morning on an empty stomach with plain water only, and the client must remain upright for at least 30 minutes to prevent esophagitis from reflux of the drug. Food, calcium supplements, and other medications all reduce alendronate absorption if taken at the same time. The difficulty swallowing is also a contraindication flag requiring provider evaluation. Option a is incorrect because taking alendronate at bedtime with juice violates both the upright posture requirement and the food-free window. Lying down after taking a bisphosphonate allows the drug to pool against the esophageal mucosa, causing erosive esophagitis. Calcium in juice also binds the drug and blocks absorption. Option b is incorrect because food taken with alendronate reduces its already low bioavailability by more than 60%. Combining it with ibuprofen adds gastrointestinal irritation risk on top of the esophagitis risk from taking the bisphosphonate with a meal. Option c is incorrect

Correct Answer: Hydroxychloroquine accumulates in retinal pigment cells and can cause progressive retinal toxicity leading to irreversible vision loss if not detected early.

Hydroxychloroquine concentrates in the retinal pigment epithelium over time and can cause a specific toxicity pattern called bull's-eye maculopathy. If not detected during routine ophthalmologic screening, it progresses to irreversible central vision loss. Regular eye exams are mandatory and any visual disturbance must be reported immediately. Option b is incorrect because dry eye from tear film disruption is not a recognized specific toxicity of hydroxychloroquine. Corneal microdeposits can occur but are generally benign and reversible, and they are not the sight-threatening adverse effect requiring mandatory ophthalmologic monitoring. Option c is incorrect because elevated intraocular pressure leading to glaucoma is not an adverse effect associated with hydroxychloroquine. Glaucoma risk is linked to long-term corticosteroid use, not to antimalarial-derived DMARDs, and confusing the two would direct monitoring to the wrong ocular structure. Option d is incorrect because lens opac

Correct Answer: Notify the provider immediately of signs of neurovascular compromise.

Pallor, coolness, prolonged capillary refill, numbness, and opioid-unresponsive pain are the hallmark signs of neurovascular compromise, potentially compartment syndrome. Irreversible tissue damage occurs within four to six hours without decompression; immediate provider notification is the priority to enable rapid evaluation and surgical intervention if needed. Option a is incorrect because waiting one hour when five classic signs of neurovascular compromise are simultaneously present allows tissue ischemia to progress toward irreversible injury. These findings constitute a clinical emergency, not a monitoring situation. Option b is incorrect because more morphine would temporarily mask the pain — the most critical indicator of compartment syndrome — without treating the vascular compromise. Applying warmth increases metabolic demand in already ischemic tissue, potentially accelerating the cellular injury. Option d is incorrect because ice reduces blood flow further in a limb already

Correct Answer: Long-term corticosteroid use, postmenopausal state, advancing age, smoking, and excessive alcohol intake combined.

Secondary osteoporosis from long-term corticosteroid therapy accelerates bone resorption and impairs osteoblast function. Combined with postmenopausal estrogen deficiency, advanced age, smoking, and nightly alcohol — each of which independently reduces bone density — these factors converge to explain the T-score of -3.3 and the pathological fracture. Option a is incorrect because polymyalgia rheumatica as a diagnosis does not increase fracture risk on its own, and medical follow-up is protective rather than harmful. The steroid treatment for the condition, not the condition itself, drives the bone density loss in this client. Option c is incorrect because identifying the coughing episode and spinal anatomy as the primary contributors confuses the precipitating event with the underlying cause. Pathological fracture from a cough occurs only because the bone is already severely weakened by multiple converging risk factors; the cough is a trigger, not an etiology. Option d is incorrect bec