HESI - Medical Surgical Nursing test-
Exam FOR MEDICAL SURGICAL
NURSING 11TH EDITION IGNATAVICIUS
QUESTIONS AND ANSWERS
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 - Correct Answer - 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 - Correct Answer - 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 - Correct Answer - 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 - Correct Answer - 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 - Correct
Answer - 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 - Correct Answer - 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
, c. document the finding
d. stop the IV infusion - Correct Answer - D
Potassium is a severe tissue irritant. The safest action is to discontinue the solution
that contains the potassium and discontinue the IV altogether, in which case the
client would need another site started. Assessing for a blood return may or may not
be successful. The solution could be diluted (less potassium) and the rate could be
slowed once it is determined that the needle is in the vein.
A nurse is caring for an older adult client who lives alone. Which economic situation
presents the most serious problem for this client?
a. costs of creating a living will
b. stock market fluctuations
c. increased provider benefits
d. social security as the basis of income - Correct Answer - D
Older adults on fixed incomes are unable to adjust their income to meet rising costs
associated with meeting basic needs
Controlling pain is important to promoting wellness. Unrelieved pain has been
associated with
a. prolonged stress response and a cascade 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 - Correct Answer - 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, catecholamines, and
glucagon. Insulin and testosterone levels decrease. Increased endocrine activity in
Exam FOR MEDICAL SURGICAL
NURSING 11TH EDITION IGNATAVICIUS
QUESTIONS AND ANSWERS
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 - Correct Answer - 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 - Correct Answer - 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 - Correct Answer - 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 - Correct Answer - 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 - Correct
Answer - 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 - Correct Answer - 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
, c. document the finding
d. stop the IV infusion - Correct Answer - D
Potassium is a severe tissue irritant. The safest action is to discontinue the solution
that contains the potassium and discontinue the IV altogether, in which case the
client would need another site started. Assessing for a blood return may or may not
be successful. The solution could be diluted (less potassium) and the rate could be
slowed once it is determined that the needle is in the vein.
A nurse is caring for an older adult client who lives alone. Which economic situation
presents the most serious problem for this client?
a. costs of creating a living will
b. stock market fluctuations
c. increased provider benefits
d. social security as the basis of income - Correct Answer - D
Older adults on fixed incomes are unable to adjust their income to meet rising costs
associated with meeting basic needs
Controlling pain is important to promoting wellness. Unrelieved pain has been
associated with
a. prolonged stress response and a cascade 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 - Correct Answer - 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, catecholamines, and
glucagon. Insulin and testosterone levels decrease. Increased endocrine activity in
