HESI - Medical Surgical Nursing test-Exam TEST BANK FOR MEDICAL SUR
CAL NURSING 11TH EDITION IGNATAVICIUS
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The nurse is assessing a group of clients.
Which clients are at greater risk for hy-
pothermia or frostbite? (select all that
apply) C, D, E, F
a. an older woman with hypertension clients with poor nutrition, fatigue, and
b. a young man with a body mass index multiple chronic illnesses are at greater
of 42 risk for hypothermia. Clients who smoke,
c. a young many who has just consumed consume alcohol, or have impaired pe-
six martinis ripheral circulation have a higher inci-
d. an older man who smokes a pack of dence of frostbite.
cigarettes a day
e. a young woman who is anorexic
f. a young woman who is diabetic
B
The nurse is caring for four clients. Which
client assessment is the most indicative
At times clients are unable to verbalize
of having pain?
that they are in pain but there are indica-
tors that the client may have acute pain
A) Client stating that he is "anxious"
such as increased heart rate, increased
B) Heart rate of 105 beats/min and rest-
blood pressure, increased respirations,
lessness
sweating, restlessness, and overall dis-
C) Blood pressure 150/70 mm Hg and
tress. All the other distractors could indi-
sleeping
cate clients who have the potential for be-
D) Postoperative client with a neck inci-
ing in pain, but restlessness with tachy-
sion
cardia is the most indicative.
C. Informal teaching is individualized one
When describing patient education ap- on one teaching which represents the
proaches, the nurse educator would ex- majority of patient education done by
plain that informal teaching is an ap- nurses that occurs when an intervention
proach that is explained or a question is answered.
Group needs are often the focus of for-
a. follows formalized plans mal patient education courses or class-
b. has standardized content es. Informal teaching does not neces-
c. often occurs one-to-one sarily follow a specific formalized plan. It
d. addresses group needs may be planned with specific content, but
it is individualized responses to patient
, HESI - Medical Surgical Nursing test-Exam TEST BANK FOR MEDICAL SUR
CAL NURSING 11TH EDITION IGNATAVICIUS
Study online at https://quizlet.com/_fw6wba
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
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
, HESI - Medical Surgical Nursing test-Exam TEST BANK FOR MEDICAL SUR
CAL NURSING 11TH EDITION IGNATAVICIUS
Study online at https://quizlet.com/_fw6wba
a. admin tylenol 650 mg orally
his body with cool water. Lowering body
b. encourage rest, and reassess in 15
temp by drinking cool fluids or taking
minutes
acetaminophen is not as effective in an
c. sponge the victim with cool water and
emergency situation. The client needs to
remove his shirt
be cooled quickly and is a priority for
d. encourage drinking of cool water or
treatment
sports drink
D
The client is receiving an IV of 60 mEq
of potassium chloride ina 1000 mL so-
Potassium is a severe tissue irritant. The
lution of dextrose 5% in 0.45% saline.
safest action is to discontinue the so-
The client states that the area around the
lution that contains the potassium and
IV site burns. What intervention does the
discontinue the IV altogether, in which
nurse perform first?
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
Controlling pain is important to promot-
ing wellness. Unrelieved pain has been
associated with
a. prolonged stress response and a cas-
cade of harmful effects system wide.
b. decreased tumor growth and longevity
c. large tidal volumes and decreased
lung capacity
d. decreased carbohydrate, protein, and
fat destruction
, HESI - Medical Surgical Nursing test-Exam TEST BANK FOR MEDICAL SUR
CAL NURSING 11TH EDITION IGNATAVICIUS
Study online at https://quizlet.com/_fw6wba
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
harmful effects in all body systems. The
stress response causes the endocrine
system to release excessive amounts
of hormones, such as cortisol, cate-
cholamines, and glucagon. Insulin and
testosterone levels decrease. Increased
endocrine activity in turn initiates a num-
ber of metabolic processes, in particular,
accelerated carbohydrate, protein, and
fat destruction, whcih can result in weight
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-
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
CAL NURSING 11TH EDITION IGNATAVICIUS
Study online at https://quizlet.com/_fw6wba
The nurse is assessing a group of clients.
Which clients are at greater risk for hy-
pothermia or frostbite? (select all that
apply) C, D, E, F
a. an older woman with hypertension clients with poor nutrition, fatigue, and
b. a young man with a body mass index multiple chronic illnesses are at greater
of 42 risk for hypothermia. Clients who smoke,
c. a young many who has just consumed consume alcohol, or have impaired pe-
six martinis ripheral circulation have a higher inci-
d. an older man who smokes a pack of dence of frostbite.
cigarettes a day
e. a young woman who is anorexic
f. a young woman who is diabetic
B
The nurse is caring for four clients. Which
client assessment is the most indicative
At times clients are unable to verbalize
of having pain?
that they are in pain but there are indica-
tors that the client may have acute pain
A) Client stating that he is "anxious"
such as increased heart rate, increased
B) Heart rate of 105 beats/min and rest-
blood pressure, increased respirations,
lessness
sweating, restlessness, and overall dis-
C) Blood pressure 150/70 mm Hg and
tress. All the other distractors could indi-
sleeping
cate clients who have the potential for be-
D) Postoperative client with a neck inci-
ing in pain, but restlessness with tachy-
sion
cardia is the most indicative.
C. Informal teaching is individualized one
When describing patient education ap- on one teaching which represents the
proaches, the nurse educator would ex- majority of patient education done by
plain that informal teaching is an ap- nurses that occurs when an intervention
proach that is explained or a question is answered.
Group needs are often the focus of for-
a. follows formalized plans mal patient education courses or class-
b. has standardized content es. Informal teaching does not neces-
c. often occurs one-to-one sarily follow a specific formalized plan. It
d. addresses group needs may be planned with specific content, but
it is individualized responses to patient
, HESI - Medical Surgical Nursing test-Exam TEST BANK FOR MEDICAL SUR
CAL NURSING 11TH EDITION IGNATAVICIUS
Study online at https://quizlet.com/_fw6wba
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
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
, HESI - Medical Surgical Nursing test-Exam TEST BANK FOR MEDICAL SUR
CAL NURSING 11TH EDITION IGNATAVICIUS
Study online at https://quizlet.com/_fw6wba
a. admin tylenol 650 mg orally
his body with cool water. Lowering body
b. encourage rest, and reassess in 15
temp by drinking cool fluids or taking
minutes
acetaminophen is not as effective in an
c. sponge the victim with cool water and
emergency situation. The client needs to
remove his shirt
be cooled quickly and is a priority for
d. encourage drinking of cool water or
treatment
sports drink
D
The client is receiving an IV of 60 mEq
of potassium chloride ina 1000 mL so-
Potassium is a severe tissue irritant. The
lution of dextrose 5% in 0.45% saline.
safest action is to discontinue the so-
The client states that the area around the
lution that contains the potassium and
IV site burns. What intervention does the
discontinue the IV altogether, in which
nurse perform first?
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
Controlling pain is important to promot-
ing wellness. Unrelieved pain has been
associated with
a. prolonged stress response and a cas-
cade of harmful effects system wide.
b. decreased tumor growth and longevity
c. large tidal volumes and decreased
lung capacity
d. decreased carbohydrate, protein, and
fat destruction
, HESI - Medical Surgical Nursing test-Exam TEST BANK FOR MEDICAL SUR
CAL NURSING 11TH EDITION IGNATAVICIUS
Study online at https://quizlet.com/_fw6wba
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
harmful effects in all body systems. The
stress response causes the endocrine
system to release excessive amounts
of hormones, such as cortisol, cate-
cholamines, and glucagon. Insulin and
testosterone levels decrease. Increased
endocrine activity in turn initiates a num-
ber of metabolic processes, in particular,
accelerated carbohydrate, protein, and
fat destruction, whcih can result in weight
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-
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
