HESI - Medical Surgical Nursing
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C. Informal teaching is individualized one
on one teaching which represents the
majority of patient education done by
When describing patient education ap-
nurses that occurs when an intervention
proaches, the nurse educator would ex-
is explained or a question is answered.
plain that informal teaching is an ap-
Group needs are often the focus of for-
proach that
mal patient education courses or class-
es. Informal teaching does not neces-
a. follows formalized plans
sarily follow a specific formalized plan. It
b. has standardized content
may be planned with specific content, but
c. often occurs one-to-one
it is individualized responses to patient
d. addresses group needs
needs. Formal teaching involves the use
of a curriculum/course plan with stan-
dardized content.
A patient expresses a strong interest in
returning to their work, family, and hob- C. Cognitive theorists believe that atten-
bies after having a stroke. Which theory tion, relevance, confidence, and satis-
type would the nurse use to develop a faction (ARCS) are the conditions that,
plan of care for the best results of this when integrated, motivate someone to
patient's motivation style? learn. Field theorists place significance
on how achievement, power, the need for
a. field affiliation, and avoidance motives influ-
b. biological ence individual behavior. Sociologic the-
c. cognitive ories are not involved in motivation.
d. sociologic
The nurse is assessing a group of clients.
Which clients are at greater risk for hy-
pothermia or frostbite? (select all that C, D, E, F
apply)
clients with poor nutrition, fatigue, and
a. an older woman with hypertension multiple chronic illnesses are at greater
b. a young man with a body mass index risk for hypothermia. Clients who smoke,
of 42 consume alcohol, or have impaired pe-
c. a young many who has just consumed ripheral circulation have a higher inci-
six martinis dence of frostbite.
d. an older man who smokes a pack of
cigarettes a day
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e. a young woman who is anorexic
f. a young woman who is diabetic
Which statement made by a nurse repre-
sents the need for further education re-
garding pain management in older adult
clients? D
a. older adults tend to report pain less There is no evidence to support the
often than younger adults idea that older adult clients perceive pain
b. older clients usually have more expe- any differently than younger clients. The
rience with pain than younger clients other statements are accurate regarding
c. older adults are at greatest risk for older clients and pain.
under treated pain
d. older clients have a different pain
mechanism and do not feel it as much
The nurse is working at a first aid booth
for a spring training game on a hot day.
C
A spectator comes in, reporting that he
is not feeling well. Vital signs are temp
The spectator shows signs of heat
104.1 F, pulse 132 BPM, respirs 26
stroke, which is a medical emergency.
breaths/min, and blood pressure 106/66
The spectator should be transported to
mm Hg. He trips over his feet as the
the ED ASAP. The nurs should take ac-
nurse leads him to a cot. What is the
tions to lower his body temp in teh mean-
priory action of the nurse?
time by removing his shirt and sponging
his body with cool water. Lowering body
a. admin tylenol 650 mg orally
temp by drinking cool fluids or taking
b. encourage rest, and reassess in 15
acetaminophen is not as effective in an
minutes
emergency situation. The client needs to
c. sponge the victim with cool water and
be cooled quickly and is a priority for
remove his shirt
treatment
d. encourage drinking of cool water or
sports drink
The client is receiving an IV of 60 mEq D
of potassium chloride ina 1000 mL so-
lution of dextrose 5% in 0.45% saline. Potassium is a severe tissue irritant. The
The client states that the area around the safest action is to discontinue the so-
IV site burns. What intervention does the lution that contains the potassium and
nurse perform first? discontinue the IV altogether, in which
, HESI - Medical Surgical Nursing
Study online at https://quizlet.com/_1dp8tn
case the client would need another site
started. Assessing for a blood return may
a. assess for a blood return
or may not be successful. The solution
b. notify the physician
could be diluted (less potassium) and the
c. document the finding
rate could be slowed once it is deter-
d. stop the IV infusion
mined that the needle is in the vein.
A nurse is caring for an older adult client
who lives alone. Which economic situa-
D
tion presents the most serious problem
for this client?
Older adults on fixed incomes are un-
able to adjust their income to meet ris-
a. costs of creating a living will
ing costs associated with meeting basic
b. stock market fluctuations
needs
c. increased provider benefits
d. social security as the basis of income
A
Pain triggers a number of physiologic
stress responses in the human body.
Unrelieved pain can prolong the stress
response and produce a cascade of
Controlling pain is important to promot- harmful effects in all body systems. The
ing wellness. Unrelieved pain has been stress response causes the endocrine
associated with system to release excessive amounts
of hormones, such as cortisol, cate-
a. prolonged stress response and a cas- cholamines, and glucagon. Insulin and
cade of harmful effects system wide. testosterone levels decrease. Increased
b. decreased tumor growth and longevity endocrine activity in turn initiates a num-
c. large tidal volumes and decreased ber of metabolic processes, in particular,
lung capacity accelerated carbohydrate, protein, and
d. decreased carbohydrate, protein, and fat destruction, whcih can result in weight
fat destruction loss, tachycardia, increased respiratory
rate, shock, and even death. The im-
mune system is also affected by pain as
demonstrated by research showing a link
between unrelieved pain and a higher
incidence of nosocomial infections and
increased tumor growth. Large tidal vol-
, HESI - Medical Surgical Nursing
Study online at https://quizlet.com/_1dp8tn
umes are not associated with pain while
decreased lung capacity is associated
with unrelieved pain. Decreased tumor
growth and longevity are not associated
with unrelieved pain. Decreased carbs,
protein, and fat are not associated with
pain or stress response.
A
Which intervention in a client with dehy-
Dehydration most frequently leads to
dration induced confusion is most likely
poor cerebra perfusion and cerebral hy-
to relieve the confusion?
poxia, causing confusion. Applying oxy-
a. increasing the IV flow rate to 250 mL/hr
gen can reduce confusion, even if perfu-
b. applying oxygen by mask or nasal can-
sion is still less than optimum. Increasing
nula
the IV flow rate would increase perfusion.
c. placing the client in a high Fowler's
However, depending on the degree of
position
dehydration, rehydrating the person too
d. Measuring intake and output every
rapidly with IV fluids can lead to cerebral
four hours
edema.
Which client is at greatest risk for dehy-
C
dration?
Older adults, because they have less to-
a. younger adult client on bedrest
tal body water than younger adults, are at
b. older adult client receiving hypotonic
greater risk for development of dehydra-
IV fluid
tion. Anyone who is cognitively impaired
c. older adult client with cognitive impair-
and cannot obtain fluids independently
ment
or cannot make his or her need for fluids
d. younger adult client receiving hyper-
known is at high risk for dehydration
tonic IV fluid
A nurse is caring for several clients.
Which client does the nurse assess most B
carefully for hyperkalemia?
Many salt substitutes are composed of
a. client with type 2 diabetes taking an potassium chloride. Heavy use cna con-
oral anti-diabetic agent tribute to the development of hyper-
b. client with heart failure using a salt kalemia. The client should be taught to
substitute read labels and to choose a salt sub-
c. client taking a thiazide diuretic for hy- stitute that does not contain potassium.
pertension
Study online at https://quizlet.com/_1dp8tn
C. Informal teaching is individualized one
on one teaching which represents the
majority of patient education done by
When describing patient education ap-
nurses that occurs when an intervention
proaches, the nurse educator would ex-
is explained or a question is answered.
plain that informal teaching is an ap-
Group needs are often the focus of for-
proach that
mal patient education courses or class-
es. Informal teaching does not neces-
a. follows formalized plans
sarily follow a specific formalized plan. It
b. has standardized content
may be planned with specific content, but
c. often occurs one-to-one
it is individualized responses to patient
d. addresses group needs
needs. Formal teaching involves the use
of a curriculum/course plan with stan-
dardized content.
A patient expresses a strong interest in
returning to their work, family, and hob- C. Cognitive theorists believe that atten-
bies after having a stroke. Which theory tion, relevance, confidence, and satis-
type would the nurse use to develop a faction (ARCS) are the conditions that,
plan of care for the best results of this when integrated, motivate someone to
patient's motivation style? learn. Field theorists place significance
on how achievement, power, the need for
a. field affiliation, and avoidance motives influ-
b. biological ence individual behavior. Sociologic the-
c. cognitive ories are not involved in motivation.
d. sociologic
The nurse is assessing a group of clients.
Which clients are at greater risk for hy-
pothermia or frostbite? (select all that C, D, E, F
apply)
clients with poor nutrition, fatigue, and
a. an older woman with hypertension multiple chronic illnesses are at greater
b. a young man with a body mass index risk for hypothermia. Clients who smoke,
of 42 consume alcohol, or have impaired pe-
c. a young many who has just consumed ripheral circulation have a higher inci-
six martinis dence of frostbite.
d. an older man who smokes a pack of
cigarettes a day
, HESI - Medical Surgical Nursing
Study online at https://quizlet.com/_1dp8tn
e. a young woman who is anorexic
f. a young woman who is diabetic
Which statement made by a nurse repre-
sents the need for further education re-
garding pain management in older adult
clients? D
a. older adults tend to report pain less There is no evidence to support the
often than younger adults idea that older adult clients perceive pain
b. older clients usually have more expe- any differently than younger clients. The
rience with pain than younger clients other statements are accurate regarding
c. older adults are at greatest risk for older clients and pain.
under treated pain
d. older clients have a different pain
mechanism and do not feel it as much
The nurse is working at a first aid booth
for a spring training game on a hot day.
C
A spectator comes in, reporting that he
is not feeling well. Vital signs are temp
The spectator shows signs of heat
104.1 F, pulse 132 BPM, respirs 26
stroke, which is a medical emergency.
breaths/min, and blood pressure 106/66
The spectator should be transported to
mm Hg. He trips over his feet as the
the ED ASAP. The nurs should take ac-
nurse leads him to a cot. What is the
tions to lower his body temp in teh mean-
priory action of the nurse?
time by removing his shirt and sponging
his body with cool water. Lowering body
a. admin tylenol 650 mg orally
temp by drinking cool fluids or taking
b. encourage rest, and reassess in 15
acetaminophen is not as effective in an
minutes
emergency situation. The client needs to
c. sponge the victim with cool water and
be cooled quickly and is a priority for
remove his shirt
treatment
d. encourage drinking of cool water or
sports drink
The client is receiving an IV of 60 mEq D
of potassium chloride ina 1000 mL so-
lution of dextrose 5% in 0.45% saline. Potassium is a severe tissue irritant. The
The client states that the area around the safest action is to discontinue the so-
IV site burns. What intervention does the lution that contains the potassium and
nurse perform first? discontinue the IV altogether, in which
, HESI - Medical Surgical Nursing
Study online at https://quizlet.com/_1dp8tn
case the client would need another site
started. Assessing for a blood return may
a. assess for a blood return
or may not be successful. The solution
b. notify the physician
could be diluted (less potassium) and the
c. document the finding
rate could be slowed once it is deter-
d. stop the IV infusion
mined that the needle is in the vein.
A nurse is caring for an older adult client
who lives alone. Which economic situa-
D
tion presents the most serious problem
for this client?
Older adults on fixed incomes are un-
able to adjust their income to meet ris-
a. costs of creating a living will
ing costs associated with meeting basic
b. stock market fluctuations
needs
c. increased provider benefits
d. social security as the basis of income
A
Pain triggers a number of physiologic
stress responses in the human body.
Unrelieved pain can prolong the stress
response and produce a cascade of
Controlling pain is important to promot- harmful effects in all body systems. The
ing wellness. Unrelieved pain has been stress response causes the endocrine
associated with system to release excessive amounts
of hormones, such as cortisol, cate-
a. prolonged stress response and a cas- cholamines, and glucagon. Insulin and
cade of harmful effects system wide. testosterone levels decrease. Increased
b. decreased tumor growth and longevity endocrine activity in turn initiates a num-
c. large tidal volumes and decreased ber of metabolic processes, in particular,
lung capacity accelerated carbohydrate, protein, and
d. decreased carbohydrate, protein, and fat destruction, whcih can result in weight
fat destruction loss, tachycardia, increased respiratory
rate, shock, and even death. The im-
mune system is also affected by pain as
demonstrated by research showing a link
between unrelieved pain and a higher
incidence of nosocomial infections and
increased tumor growth. Large tidal vol-
, HESI - Medical Surgical Nursing
Study online at https://quizlet.com/_1dp8tn
umes are not associated with pain while
decreased lung capacity is associated
with unrelieved pain. Decreased tumor
growth and longevity are not associated
with unrelieved pain. Decreased carbs,
protein, and fat are not associated with
pain or stress response.
A
Which intervention in a client with dehy-
Dehydration most frequently leads to
dration induced confusion is most likely
poor cerebra perfusion and cerebral hy-
to relieve the confusion?
poxia, causing confusion. Applying oxy-
a. increasing the IV flow rate to 250 mL/hr
gen can reduce confusion, even if perfu-
b. applying oxygen by mask or nasal can-
sion is still less than optimum. Increasing
nula
the IV flow rate would increase perfusion.
c. placing the client in a high Fowler's
However, depending on the degree of
position
dehydration, rehydrating the person too
d. Measuring intake and output every
rapidly with IV fluids can lead to cerebral
four hours
edema.
Which client is at greatest risk for dehy-
C
dration?
Older adults, because they have less to-
a. younger adult client on bedrest
tal body water than younger adults, are at
b. older adult client receiving hypotonic
greater risk for development of dehydra-
IV fluid
tion. Anyone who is cognitively impaired
c. older adult client with cognitive impair-
and cannot obtain fluids independently
ment
or cannot make his or her need for fluids
d. younger adult client receiving hyper-
known is at high risk for dehydration
tonic IV fluid
A nurse is caring for several clients.
Which client does the nurse assess most B
carefully for hyperkalemia?
Many salt substitutes are composed of
a. client with type 2 diabetes taking an potassium chloride. Heavy use cna con-
oral anti-diabetic agent tribute to the development of hyper-
b. client with heart failure using a salt kalemia. The client should be taught to
substitute read labels and to choose a salt sub-
c. client taking a thiazide diuretic for hy- stitute that does not contain potassium.
pertension
