HESI - Medical Surgical Nursing test-Exam TEST
BANK FOR MEDICAL SURGICAL NURSING
11TH EDITION IGNATAVICIUS 100% correct
The nurse is assessing a group of clients. C, D, E,
F Which clients are at greater risk for
hypothermia or frostbite? (select all that clients with poor nutrition, fatigue, and multiple
chronic apply) illnesses are at greater risk for hypothermia. Clients
who
smoke, consume alcohol, or have impaired peripheral
a.an older woman with hypertension circulation have a higher incidence of frostbite.
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
,The nurse is caring for four clients. Which
B client assessment is the most indicative of
having pain? At times clients are unable to verbalize that they are in
pain but there are indicators that the client may have
acute pain
A) Client stating that he is "anxious" such as increased heart rate, increased blood pressure,
B) Heart rate of 105 beats/min and increased respirations, sweating, restlessness, and
overall restlessness distress. All the other distractors could indicate clients
who
C) Blood pressure 150/70 mm Hg and have the potential for being in pain, but restlessness
with sleeping tachycardia is the most indicative.
D) Postoperative client with a neck incision
When describing patient education C. Informal teaching is individualized one on one
teaching approaches, the nurse educator would which represents the majority of patient
education done by explain that informal teaching is an nurses that occurs when an
intervention is explained or a
approach that question is answered. Group needs are often the focus of
formal patient education courses or classes. Informal
teaching
a.follows formalized plans does not necessarily follow a specific formalized plan. It
may
b. has standardized content be planned with specific content, but it is individualized
c. often occurs one-to-one responses to patient needs. Formal teaching involves the use
d. addresses group needs of a curriculum/course plan with standardized content.
A patient expresses a strong interest in C. Cognitive theorists believe that attention, relevance,
returning to their work, family, and hobbies confidence, and satisfaction (ARCS) are the conditions
that, after having a stroke. Which theory type when integrated, motivate someone to learn.
Field theorists would the nurse use to develop a plan of place significance on how achievement,
power, the need for care for the best results of this patient's affiliation, and avoidance motives
influence individual motivation style? behavior. Sociologic theories are not involved in
motivation.
a.field
b. biological
c. cognitive
d. sociologic
Which statement made by a nurse D
represents the need for further education
regarding pain management in older adult There is no evidence to support the idea that older adult
clients? clients perceive pain any differently than younger clients.
The other statements are accurate regarding older
clients and
a.older adults tend to report pain less often pain.
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
,The nurse is working at a first aid booth C
for a spring training game on a hot day.
A The spectator shows signs of heat stroke, which is a
spectator comes in, reporting that he is medical emergency. The spectator should be
not feeling well. Vital signs are temp transported to the ED ASAP. The nurs should take
104.1 F, actions to lower his body temp in teh meantime by
pulse 132 BPM, respirs 26 breaths/min, and removing his shirt and sponging his body with cool
blood pressure 106/66 mm Hg. He trips water. Lowering body temp by drinking cool fluids or
over his feet as the nurse leads him to a taking acetaminophen is not as effective in an emergency
cot. What is the priory action of the situation. The client needs to be cooled quickly and is a
nurse? priority for treatment
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
The client is receiving an IV of 60 mEq of D
potassium chloride ina 1000 mL solution of
dextrose 5% in 0.45% saline. The client Potassium is a severe tissue irritant. The safest action is
states that the area around the IV site to discontinue the solution that contains the potassium
burns. What and discontinue the IV altogether, in which case the client
intervention does the nurse perform first? would
need another site started. Assessing for a blood return may
a.assess for a blood return or may not be successful. The solution could be diluted
b. notify the physician (less
c. document the finding potassium) and the rate could be slowed once
d. stop the IV infusion it is determined that the needle is in the
vein.
A nurse is caring for an older adult D
client who lives alone. Which economic
situation presents the most serious Older adults on fixed incomes are unable to adjust
problem for this client? their income to meet rising costs associated with
meeting basic needs
a. costs of creating a living will
b. stock market fluctuations
c. increased provider benefits
d. social security as the basis of income
, Controlling pain is important to promoting A
wellness. Unrelieved pain has been
associated with Pain triggers a number of physiologic stress responses in
the human body. Unrelieved pain can prolong the stress
a. prolonged stress response and a response and produce a cascade of harmful effects in all
cascade of harmful effects system wide. body systems. The stress response causes the endocrine
b. decreased tumor growth and longevity system to release excessive amounts of hormones, such
c. large tidal volumes and decreased as cortisol,
lung capacity catecholamines, and glucagon. Insulin and testosterone levels
d. decreased carbohydrate, protein, and fat decrease. Increased endocrine activity in turn initiates a
destruction number 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 immune 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 volumes 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.
Which intervention in a client with A
dehydration induced confusion is most Dehydration most frequently leads to poor cerebra
likely to relieve the confusion? perfusion and cerebral hypoxia, causing confusion.
a. increasing the IV flow rate to 250 mL/hr Applying oxygen can reduce confusion, even if
b. applying oxygen by mask or perfusion is still less than optimum. Increasing the IV
nasal cannula flow rate would increase perfusion. However, depending
c. placing the client in a high on the degree of dehydration, rehydrating the person too
Fowler's position rapidly with IV fluids can lead to
d. Measuring intake and output every cerebral edema.
four hours
Which client is at greatest risk for C
dehydration?
Older adults, because they have less total body water than
a. younger adult client on bedrest younger adults, are at greater risk for development of
b. older adult client receiving hypotonic dehydration. Anyone who is cognitively impaired and cannot
IV fluid obtain fluids independently or cannot make his or her
c. older adult client with need for fluids known is at high risk for dehydration
cognitive impairment
d. younger adult client receiving
hypertonic IV fluid
BANK FOR MEDICAL SURGICAL NURSING
11TH EDITION IGNATAVICIUS 100% correct
The nurse is assessing a group of clients. C, D, E,
F Which clients are at greater risk for
hypothermia or frostbite? (select all that clients with poor nutrition, fatigue, and multiple
chronic apply) illnesses are at greater risk for hypothermia. Clients
who
smoke, consume alcohol, or have impaired peripheral
a.an older woman with hypertension circulation have a higher incidence of frostbite.
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
,The nurse is caring for four clients. Which
B client assessment is the most indicative of
having pain? At times clients are unable to verbalize that they are in
pain but there are indicators that the client may have
acute pain
A) Client stating that he is "anxious" such as increased heart rate, increased blood pressure,
B) Heart rate of 105 beats/min and increased respirations, sweating, restlessness, and
overall restlessness distress. All the other distractors could indicate clients
who
C) Blood pressure 150/70 mm Hg and have the potential for being in pain, but restlessness
with sleeping tachycardia is the most indicative.
D) Postoperative client with a neck incision
When describing patient education C. Informal teaching is individualized one on one
teaching approaches, the nurse educator would which represents the majority of patient
education done by explain that informal teaching is an nurses that occurs when an
intervention is explained or a
approach that question is answered. Group needs are often the focus of
formal patient education courses or classes. Informal
teaching
a.follows formalized plans does not necessarily follow a specific formalized plan. It
may
b. has standardized content be planned with specific content, but it is individualized
c. often occurs one-to-one responses to patient needs. Formal teaching involves the use
d. addresses group needs of a curriculum/course plan with standardized content.
A patient expresses a strong interest in C. Cognitive theorists believe that attention, relevance,
returning to their work, family, and hobbies confidence, and satisfaction (ARCS) are the conditions
that, after having a stroke. Which theory type when integrated, motivate someone to learn.
Field theorists would the nurse use to develop a plan of place significance on how achievement,
power, the need for care for the best results of this patient's affiliation, and avoidance motives
influence individual motivation style? behavior. Sociologic theories are not involved in
motivation.
a.field
b. biological
c. cognitive
d. sociologic
Which statement made by a nurse D
represents the need for further education
regarding pain management in older adult There is no evidence to support the idea that older adult
clients? clients perceive pain any differently than younger clients.
The other statements are accurate regarding older
clients and
a.older adults tend to report pain less often pain.
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
,The nurse is working at a first aid booth C
for a spring training game on a hot day.
A The spectator shows signs of heat stroke, which is a
spectator comes in, reporting that he is medical emergency. The spectator should be
not feeling well. Vital signs are temp transported to the ED ASAP. The nurs should take
104.1 F, actions to lower his body temp in teh meantime by
pulse 132 BPM, respirs 26 breaths/min, and removing his shirt and sponging his body with cool
blood pressure 106/66 mm Hg. He trips water. Lowering body temp by drinking cool fluids or
over his feet as the nurse leads him to a taking acetaminophen is not as effective in an emergency
cot. What is the priory action of the situation. The client needs to be cooled quickly and is a
nurse? priority for treatment
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
The client is receiving an IV of 60 mEq of D
potassium chloride ina 1000 mL solution of
dextrose 5% in 0.45% saline. The client Potassium is a severe tissue irritant. The safest action is
states that the area around the IV site to discontinue the solution that contains the potassium
burns. What and discontinue the IV altogether, in which case the client
intervention does the nurse perform first? would
need another site started. Assessing for a blood return may
a.assess for a blood return or may not be successful. The solution could be diluted
b. notify the physician (less
c. document the finding potassium) and the rate could be slowed once
d. stop the IV infusion it is determined that the needle is in the
vein.
A nurse is caring for an older adult D
client who lives alone. Which economic
situation presents the most serious Older adults on fixed incomes are unable to adjust
problem for this client? their income to meet rising costs associated with
meeting basic needs
a. costs of creating a living will
b. stock market fluctuations
c. increased provider benefits
d. social security as the basis of income
, Controlling pain is important to promoting A
wellness. Unrelieved pain has been
associated with Pain triggers a number of physiologic stress responses in
the human body. Unrelieved pain can prolong the stress
a. prolonged stress response and a response and produce a cascade of harmful effects in all
cascade of harmful effects system wide. body systems. The stress response causes the endocrine
b. decreased tumor growth and longevity system to release excessive amounts of hormones, such
c. large tidal volumes and decreased as cortisol,
lung capacity catecholamines, and glucagon. Insulin and testosterone levels
d. decreased carbohydrate, protein, and fat decrease. Increased endocrine activity in turn initiates a
destruction number 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 immune 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 volumes 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.
Which intervention in a client with A
dehydration induced confusion is most Dehydration most frequently leads to poor cerebra
likely to relieve the confusion? perfusion and cerebral hypoxia, causing confusion.
a. increasing the IV flow rate to 250 mL/hr Applying oxygen can reduce confusion, even if
b. applying oxygen by mask or perfusion is still less than optimum. Increasing the IV
nasal cannula flow rate would increase perfusion. However, depending
c. placing the client in a high on the degree of dehydration, rehydrating the person too
Fowler's position rapidly with IV fluids can lead to
d. Measuring intake and output every cerebral edema.
four hours
Which client is at greatest risk for C
dehydration?
Older adults, because they have less total body water than
a. younger adult client on bedrest younger adults, are at greater risk for development of
b. older adult client receiving hypotonic dehydration. Anyone who is cognitively impaired and cannot
IV fluid obtain fluids independently or cannot make his or her
c. older adult client with need for fluids known is at high risk for dehydration
cognitive impairment
d. younger adult client receiving
hypertonic IV fluid
