| Ignatavicius 11th Edition Exam Prep & Study Guide
Thexnursexisxassessingxaxgroupxofxclients.xWhichxclientsxarexatxgreaterxriskxforxhypothermiaxorxfrostbite?
x(selectxallxthatxapply)
a.xanxolderxwomanxwithxhypertension
b.xaxyoungxmanxwithxaxbodyxmassxindexxofx42
c.xaxyoungxmanyxwhoxhasxjustxconsumedxsixxmartinis
d.xanxolderxmanxwhoxsmokesxaxpackxofxcigarettesxaxday
e.xaxyoungxwomanxwhoxisxanorexic
f.xaxyoungxwomanxwhoxisxdiabeticx-xcorrectxanswerx ✅C,xD,xE,xF
clientsxwithxpoorxnutrition,xfatigue,xandxmultiplexchronicxillnessesxarexatxgreaterxriskxforxhypothermia.xC
lientsxwhoxsmoke,xconsumexalcohol,xorxhaveximpairedxperipheralxcirculationxhavexaxhigherxincidencexof
xfrostbite.
Thexnursexisxcaringxforxfourxclients.xWhichxclientxassessmentxisxthexmostxindicativexofxhavingxpain?
A)xClientxstatingxthatxhexisx"anxious"
B)xHeartxratexofx105xbeats/minxandxrestlessness
C)xBloodxpressurex150/70xmmxHgxandxsleeping
D)xPostoperativexclientxwithxaxneckxincisionx-xcorrectxanswerx ✅B
Atxtimesxclientsxarexunablextoxverbalizexthatxtheyxarexinxpainxbutxtherexarexindicatorsxthatxthexclientxma
yxhavexacutexpainxsuchxasxincreasedxheartxrate,xincreasedxbloodxpressure,xincreasedxrespirations,xsweat
ing,xrestlessness,xandxoverallxdistress.xAllxthexotherxdistractorsxcouldxindicatexclientsxwhoxhavexthexpote
ntialxforxbeingxinxpain,xbutxrestlessnessxwithxtachycardiaxisxthexmostxindicative.
Whenxdescribingxpatientxeducationxapproaches,xthexnursexeducatorxwouldxexplainxthatxinformalxteachi
ngxisxanxapproachxthat
,a.xfollowsxformalizedxplans
b.xhasxstandardizedxcontent
c.xoftenxoccursxone-to-one
d.xaddressesxgroupxneedsx-
xcorrectxanswerx ✅C.xInformalxteachingxisxindividualizedxonexonxonexteachingxwhichxrepresentsxthex
majorityxofxpatientxeducationxdonexbyxnursesxthatxoccursxwhenxanxinterventionxisxexplainedxorxaxquesti
onxisxanswered.xGroupxneedsxarexoftenxthexfocusxofxformalxpatientxeducationxcoursesxorxclasses.xInfor
malxteachingxdoesxnotxnecessarilyxfollowxaxspecificxformalizedxplan.xItxmayxbexplannedxwithxspecificxcon
tent,xbutxitxisxindividualizedxresponsesxtoxpatientxneeds.xFormalxteachingxinvolvesxthexusexofxaxcurriculu
m/coursexplanxwithxstandardizedxcontent.
Axpatientxexpressesxaxstrongxinterestxinxreturningxtoxtheirxwork,xfamily,xandxhobbiesxafterxhavingxaxstro
ke.xWhichxtheoryxtypexwouldxthexnursexusextoxdevelopxaxplanxofxcarexforxthexbestxresultsxofxthisxpatien
t'sxmotivationxstyle?
a.xfield
b.xbiological
c.xcognitive
d.xsociologicx-
xcorrectxanswerx ✅C.xCognitivextheoristsxbelievexthatxattention,xrelevance,xconfidence,xandxsatisfac
tionx(ARCS)xarexthexconditionsxthat,xwhenxintegrated,xmotivatexsomeonextoxlearn.xFieldxtheoristsxplacex
significancexonxhowxachievement,xpower,xthexneedxforxaffiliation,xandxavoidancexmotivesxinfluencexindi
vidualxbehavior.xSociologicxtheoriesxarexnotxinvolvedxinxmotivation.
Whichxstatementxmadexbyxaxnursexrepresentsxthexneedxforxfurtherxeducationxregardingxpainxmanagem
entxinxolderxadultxclients?
a.xolderxadultsxtendxtoxreportxpainxlessxoftenxthanxyoungerxadults
b.xolderxclientsxusuallyxhavexmorexexperiencexwithxpainxthanxyoungerxclients
c.xolderxadultsxarexatxgreatestxriskxforxunderxtreatedxpain
d.xolderxclientsxhavexaxdifferentxpainxmechanismxandxdoxnotxfeelxitxasxmuchx-xcorrectxanswerx ✅D
,Therexisxnoxevidencextoxsupportxthexideaxthatxolderxadultxclientsxperceivexpainxanyxdifferentlyxthanxyou
ngerxclients.xThexotherxstatementsxarexaccuratexregardingxolderxclientsxandxpain.
Thexnursexisxworkingxatxaxfirstxaidxboothxforxaxspringxtrainingxgamexonxaxhotxday.xAxspectatorxcomesxin,
xreportingxthatxhexisxnotxfeelingxwell.xVitalxsignsxarextempx104.1xF,xpulsex132xBPM,xrespirsx26xbreaths/
min,xandxbloodxpressurex106/66xmmxHg.xHextripsxoverxhisxfeetxasxthexnursexleadsxhimxtoxaxcot.xWhatxis
xthexprioryxactionxofxthexnurse?
a.xadminxtylenolx650xmgxorally
b.xencouragexrest,xandxreassessxinx15xminutes
c.xspongexthexvictimxwithxcoolxwaterxandxremovexhisxshirt
d.xencouragexdrinkingxofxcoolxwaterxorxsportsxdrinkx-xcorrectxanswerx ✅C
Thexspectatorxshowsxsignsxofxheatxstroke,xwhichxisxaxmedicalxemergency.xThexspectatorxshouldxbextrans
portedxtoxthexEDxASAP.xThexnursxshouldxtakexactionsxtoxlowerxhisxbodyxtempxinxtehxmeantimexbyxremo
vingxhisxshirtxandxspongingxhisxbodyxwithxcoolxwater.xLoweringxbodyxtempxbyxdrinkingxcoolxfluidsxorxtak
ingxacetaminophenxisxnotxasxeffectivexinxanxemergencyxsituation.xThexclientxneedsxtoxbexcooledxquicklyx
andxisxaxpriorityxforxtreatment
ThexclientxisxreceivingxanxIVxofx60xmEqxofxpotassiumxchloridexinax1000xmLxsolutionxofxdextrosex5%xinx0.
45%xsaline.xThexclientxstatesxthatxthexareaxaroundxthexIVxsitexburns.xWhatxinterventionxdoesxthexnursex
performxfirst?
a.xassessxforxaxbloodxreturn
b.xnotifyxthexphysician
c.xdocumentxthexfinding
d.xstopxthexIVxinfusionx-xcorrectxanswerx ✅D
Potassiumxisxaxseverextissuexirritant.xThexsafestxactionxisxtoxdiscontinuexthexsolutionxthatxcontainsxthexp
otassiumxandxdiscontinuexthexIVxaltogether,xinxwhichxcasexthexclientxwouldxneedxanotherxsitexstarted.x
Assessingxforxaxbloodxreturnxmayxorxmayxnotxbexsuccessful.xThexsolutionxcouldxbexdilutedx(lessxpotassiu
m)xandxthexratexcouldxbexslowedxoncexitxisxdeterminedxthatxthexneedlexisxinxthexvein.
, Axnursexisxcaringxforxanxolderxadultxclientxwhoxlivesxalone.xWhichxeconomicxsituationxpresentsxthexmost
xseriousxproblemxforxthisxclient?
a.xcostsxofxcreatingxaxlivingxwill
b.xstockxmarketxfluctuations
c.xincreasedxproviderxbenefits
d.xsocialxsecurityxasxthexbasisxofxincomex-xcorrectxanswerx ✅D
Olderxadultsxonxfixedxincomesxarexunablextoxadjustxtheirxincomextoxmeetxrisingxcostsxassociatedxwithxm
eetingxbasicxneeds
Controllingxpainxisximportantxtoxpromotingxwellness.xUnrelievedxpainxhasxbeenxassociatedxwithx
a.xprolongedxstressxresponsexandxaxcascadexofxharmfulxeffectsxsystemxwide.
b.xdecreasedxtumorxgrowthxandxlongevity
c.xlargextidalxvolumesxandxdecreasedxlungxcapacity
d.xdecreasedxcarbohydrate,xprotein,xandxfatxdestructionx-xcorrectxanswerx ✅A
Painxtriggersxaxnumberxofxphysiologicxstressxresponsesxinxthexhumanxbody.xUnrelievedxpainxcanxprolong
xthexstressxresponsexandxproducexaxcascadexofxharmfulxeffectsxinxallxbodyxsystems.xThexstressxresponse
xcausesxthexendocrinexsystemxtoxreleasexexcessivexamountsxofxhormones,xsuchxasxcortisol,xcatecholami
nes,xandxglucagon.xInsulinxandxtestosteronexlevelsxdecrease.xIncreasedxendocrinexactivityxinxturnxinitiat
esxaxnumberxofxmetabolicxprocesses,xinxparticular,xacceleratedxcarbohydrate,xprotein,xandxfatxdestructi
on,xwhcihxcanxresultxinxweightxloss,xtachycardia,xincreasedxrespiratoryxrate,xshock,xandxevenxdeath.xThe
ximmunexsystemxisxalsoxaffectedxbyxpainxasxdemonstratedxbyxresearchxshowingxaxlinkxbetweenxunreliev
edxpainxandxaxhigherxincidencexofxnosocomialxinfectionsxandxincreasedxtumorxgrowth.xLargextidalxvolu
mesxarexnotxassociatedxwithxpainxwhilexdecreasedxlungxcapacityxisxassociatedxwithxunrelievedxpain.xDec
reasedxtumorxgrowthxandxlongevityxarexnotxassociatedxwithxunrelievedxpain.xDecreasedxcarbs,xprotein,x
andxfatxarexnotxassociatedxwithxpainxorxstressxresponse.
Whichxinterventionxinxaxclientxwithxdehydrationxinducedxconfusionxisxmostxlikelyxtoxrelievexthexconfusio
n?
a.xincreasingxthexIVxflowxratextox250xmL/hr