HESI - MEDICAL SURGICAL NURSING TEST-EXAM TEST BANK FOR
MEDICAL SURGICAL NURSING 11TH EDITION IGNATAVICIUS
The nurse is assessing a group of clients. Which clients are at greater risk
for hypothermia or frostbite? (select all that apply)
a. an older woman with hypertension
b. a young man with a body mass index of 42
c. a young many who has just consumed six martinis
d. an older man who smokes a pack of cigarettes a day
e. a young woman who is anorexic
f. a young woman who is diabetic
C, D, E, F
clients with poor nutrition, fatigue, and multiple chronic illnesses are at
greater risk for hypothermia. Clients who smoke, consume alcohol, or have
impaired peripheral circulation have a higher incidence of frostbite.
The nurse is caring for four clients. Which client assessment is the most
indicative of having pain?
A) Client stating that he is "anxious"
B) Heart rate of 105 beats/min and restlessness
C) Blood pressure 150/70 mm Hg and sleeping
,D) Postoperative client with a neck incision
B
At times clients are unable to verbalize that they are in pain but there are
indicators that the client may have acute pain such as increased heart rate,
increased blood pressure, increased respirations, sweating, restlessness, and
overall distress. All the other distractors could indicate clients who have
the potential for being in pain, but restlessness with tachycardia is the most
indicative.
When describing patient education approaches, the nurse educator would explain
that informal teaching is an approach that
a. follows formalized plans
b. has standardized content
c. often occurs one-to-one
d. addresses group needs
C. Informal teaching is individualized one on one teaching which represents
the majority of patient education done by nurses that occurs when an
intervention is explained or a question is answered. Group needs are often the
focus of formal patient education courses or classes. Informal teaching does
not necessarily follow a specific formalized plan. It may be planned with
specific content, but it is individualized responses to patient needs. Formal
teaching involves the use of a curriculum/course plan with standardized
content.
,A patient expresses a strong interest in returning to their work, family, and
hobbies after having a stroke. Which theory type would the nurse use to
develop a plan of care for the best results of this patient's motivation
style?
a. field
b. biological
c. cognitive
d. sociologic
C. Cognitive theorists believe that attention, relevance, confidence, and
satisfaction (ARCS) are the conditions that, when integrated, motivate someone
to learn. Field theorists place significance on how achievement, power, the
need for affiliation, and avoidance motives influence individual behavior.
Sociologic theories are not involved in motivation.
Which statement made by a nurse represents the need for further education
regarding pain management in older adult clients?
a. older adults tend to report pain less often than younger adults
b. older clients usually have more experience with pain than younger clients
c. older adults are at greatest risk for under treated pain
d. older clients have a different pain mechanism and do not feel it as much
D
There is no evidence to support the idea that older adult clients perceive
pain any differently than younger clients. The other statements are accurate
regarding older clients and pain.
, The nurse is working at a first aid booth for a spring training game on a hot
day. A spectator comes in, reporting that he is not feeling well. Vital signs
are temp 104.1 F, pulse 132 BPM, respirs 26 breaths/min, and blood pressure
106/66 mm Hg. He trips over his feet as the nurse leads him to a cot. What is
the priory action of the nurse?
a. admin tylenol 650 mg orally
b. encourage rest, and reassess in 15 minutes
c. sponge the victim with cool water and remove his shirt
d. encourage drinking of cool water or sports drink
C
The spectator shows signs of heat stroke, which is a medical emergency. The
spectator should be transported to the ED ASAP. The nurs should take actions
to lower his body temp in teh meantime by removing his shirt and sponging his
body with cool water. Lowering body temp by drinking cool fluids or taking
acetaminophen is not as effective in an emergency situation. The client needs
to be cooled quickly and is a priority for treatment
The client is receiving an IV of 60 mEq of potassium chloride ina 1000 mL
solution of dextrose 5% in 0.45% saline. The client states that the area
around the IV site burns. What intervention does the nurse perform first?
a. assess for a blood return
b. notify the physician
MEDICAL SURGICAL NURSING 11TH EDITION IGNATAVICIUS
The nurse is assessing a group of clients. Which clients are at greater risk
for hypothermia or frostbite? (select all that apply)
a. an older woman with hypertension
b. a young man with a body mass index of 42
c. a young many who has just consumed six martinis
d. an older man who smokes a pack of cigarettes a day
e. a young woman who is anorexic
f. a young woman who is diabetic
C, D, E, F
clients with poor nutrition, fatigue, and multiple chronic illnesses are at
greater risk for hypothermia. Clients who smoke, consume alcohol, or have
impaired peripheral circulation have a higher incidence of frostbite.
The nurse is caring for four clients. Which client assessment is the most
indicative of having pain?
A) Client stating that he is "anxious"
B) Heart rate of 105 beats/min and restlessness
C) Blood pressure 150/70 mm Hg and sleeping
,D) Postoperative client with a neck incision
B
At times clients are unable to verbalize that they are in pain but there are
indicators that the client may have acute pain such as increased heart rate,
increased blood pressure, increased respirations, sweating, restlessness, and
overall distress. All the other distractors could indicate clients who have
the potential for being in pain, but restlessness with tachycardia is the most
indicative.
When describing patient education approaches, the nurse educator would explain
that informal teaching is an approach that
a. follows formalized plans
b. has standardized content
c. often occurs one-to-one
d. addresses group needs
C. Informal teaching is individualized one on one teaching which represents
the majority of patient education done by nurses that occurs when an
intervention is explained or a question is answered. Group needs are often the
focus of formal patient education courses or classes. Informal teaching does
not necessarily follow a specific formalized plan. It may be planned with
specific content, but it is individualized responses to patient needs. Formal
teaching involves the use of a curriculum/course plan with standardized
content.
,A patient expresses a strong interest in returning to their work, family, and
hobbies after having a stroke. Which theory type would the nurse use to
develop a plan of care for the best results of this patient's motivation
style?
a. field
b. biological
c. cognitive
d. sociologic
C. Cognitive theorists believe that attention, relevance, confidence, and
satisfaction (ARCS) are the conditions that, when integrated, motivate someone
to learn. Field theorists place significance on how achievement, power, the
need for affiliation, and avoidance motives influence individual behavior.
Sociologic theories are not involved in motivation.
Which statement made by a nurse represents the need for further education
regarding pain management in older adult clients?
a. older adults tend to report pain less often than younger adults
b. older clients usually have more experience with pain than younger clients
c. older adults are at greatest risk for under treated pain
d. older clients have a different pain mechanism and do not feel it as much
D
There is no evidence to support the idea that older adult clients perceive
pain any differently than younger clients. The other statements are accurate
regarding older clients and pain.
, The nurse is working at a first aid booth for a spring training game on a hot
day. A spectator comes in, reporting that he is not feeling well. Vital signs
are temp 104.1 F, pulse 132 BPM, respirs 26 breaths/min, and blood pressure
106/66 mm Hg. He trips over his feet as the nurse leads him to a cot. What is
the priory action of the nurse?
a. admin tylenol 650 mg orally
b. encourage rest, and reassess in 15 minutes
c. sponge the victim with cool water and remove his shirt
d. encourage drinking of cool water or sports drink
C
The spectator shows signs of heat stroke, which is a medical emergency. The
spectator should be transported to the ED ASAP. The nurs should take actions
to lower his body temp in teh meantime by removing his shirt and sponging his
body with cool water. Lowering body temp by drinking cool fluids or taking
acetaminophen is not as effective in an emergency situation. The client needs
to be cooled quickly and is a priority for treatment
The client is receiving an IV of 60 mEq of potassium chloride ina 1000 mL
solution of dextrose 5% in 0.45% saline. The client states that the area
around the IV site burns. What intervention does the nurse perform first?
a. assess for a blood return
b. notify the physician
