HESI - MEDICAL SURGICAL NURSING
TEST-EXAM TEST BANK FOR
MEDICAL SURGICAL NURSING 11TH
EDITION IGNATAVICIUS
The68nurse68is68assessing68a68group68of68clients.68Which68clients68are68at68greater68risk
68for68hypothermia68or68frostbite?68(select68all68that68apply)
a.68an68older68woman68with68hypertension
b.68a68young68man68with68a68body68mass68index68of6842
c.68a68young68many68who68has68just68consumed68six68martinis
d.68an68older68man68who68smokes68a68pack68of68cigarettes68a68day
e.68a68young68woman68who68is68anorexic
f.68a68young68woman68who68is68diabetic68-68answer--C,68D,68E,68F
clients68with68poor68nutrition,68fatigue,68and68multiple68chronic68illnesses68are68at68great
er68risk68for68hypothermia.68Clients68who68smoke,68consume68alcohol,68or68have68impair
ed68peripheral68circulation68have68a68higher68incidence68of68frostbite.
The68nurse68is68caring68for68four68clients.68Which68client68assessment68is68the68most68in
dicative68of68having68pain?
A)68Client68stating68that68he68is68"anxious"
B)68Heart68rate68of6810568beats/min68and68restlessness
C)68Blood68pressure68150/7068mm68Hg68and68sleeping
D)68Postoperative68client68with68a68neck68incision68-68answer--B
At68times68clients68are68unable68to68verbalize68that68they68are68in68pain68but68there68are
68indicators68that68the68client68may68have68acute68pain68such68as68increased68heart68rat
e,68increased68blood68pressure,68increased68respirations,68sweating,68restlessness,68an
d68overall68distress.68All68the68other68distractors68could68indicate68clients68who68have68t
he68potential68for68being68in68pain,68but68restlessness68with68tachycardia68is68the68most6
8indicative.
,When68describing68patient68education68approaches,68the68nurse68educator68would68expl
ain68that68informal68teaching68is68an68approach68that
a.68follows68formalized68plans
b.68has68standardized68content
c.68often68occurs68one-to-one
d.68addresses68group68needs68-68answer--
C.68Informal68teaching68is68individualized68one68on68one68teaching68which68represents68
the68majority68of68patient68education68done68by68nurses68that68occurs68when68an68interv
ention68is68explained68or68a68question68is68answered.68Group68needs68are68often68the68f
ocus68of68formal68patient68education68courses68or68classes.68Informal68teaching68does68
not68necessarily68follow68a68specific68formalized68plan.68It68may68be68planned68with68sp
ecific68content,68but68it68is68individualized68responses68to68patient68needs.68Formal68tea
ching68involves68the68use68of68a68curriculum/course68plan68with68standardized68content.
A68patient68expresses68a68strong68interest68in68returning68to68their68work,68family,68and68
hobbies68after68having68a68stroke.68Which68theory68type68would68the68nurse68use68to68d
evelop68a68plan68of68care68for68the68best68results68of68this68patient's68motivation68style?
a.68field
b.68biological
c.68cognitive
d.68sociologic68-68answer--
C.68Cognitive68theorists68believe68that68attention,68relevance,68confidence,68and68satisfa
ction68(ARCS)68are68the68conditions68that,68when68integrated,68motivate68someone68to68
learn.68Field68theorists68place68significance68on68how68achievement,68power,68the68need
68for68affiliation,68and68avoidance68motives68influence68individual68behavior.68Sociologic6
8theories68are68not68involved68in68motivation.
Which68statement68made68by68a68nurse68represents68the68need68for68further68education
68regarding68pain68management68in68older68adult68clients?
a.68older68adults68tend68to68report68pain68less68often68than68younger68adults
b.68older68clients68usually68have68more68experience68with68pain68than68younger68clients
c.68older68adults68are68at68greatest68risk68for68under68treated68pain
d.68older68clients68have68a68different68pain68mechanism68and68do68not68feel68it68as68muc
h68-68answer--D
There68is68no68evidence68to68support68the68idea68that68older68adult68clients68perceive68p
ain68any68differently68than68younger68clients.68The68other68statements68are68accurate68r
egarding68older68clients68and68pain.
The68nurse68is68working68at68a68first68aid68booth68for68a68spring68training68game68on68a6
8hot68day.68A68spectator68comes68in,68reporting68that68he68is68not68feeling68well.68Vital68
signs68are68temp68104.168F,68pulse6813268BPM,68respirs682668breaths/
,min,68and68blood68pressure68106/6668mm68Hg.68He68trips68over68his68feet68as68the68nur
se68leads68him68to68a68cot.68What68is68the68priory68action68of68the68nurse?
a.68admin68tylenol6865068mg68orally
b.68encourage68rest,68and68reassess68in681568minutes
c.68sponge68the68victim68with68cool68water68and68remove68his68shirt
d.68encourage68drinking68of68cool68water68or68sports68drink68-68answer--C
The68spectator68shows68signs68of68heat68stroke,68which68is68a68medical68emergency.68T
he68spectator68should68be68transported68to68the68ED68ASAP.68The68nurs68should68take6
8actions68to68lower68his68body68temp68in68teh68meantime68by68removing68his68shirt68and
68sponging68his68body68with68cool68water.68Lowering68body68temp68by68drinking68cool68fl
uids68or68taking68acetaminophen68is68not68as68effective68in68an68emergency68situation.68
The68client68needs68to68be68cooled68quickly68and68is68a68priority68for68treatment
The68client68is68receiving68an68IV68of686068mEq68of68potassium68chloride68ina68100068m
L68solution68of68dextrose685%68in680.45%68saline.68The68client68states68that68the68area68
around68the68IV68site68burns.68What68intervention68does68the68nurse68perform68first?
a.68assess68for68a68blood68return
b.68notify68the68physician
c.68document68the68finding
d.68stop68the68IV68infusion68-68answer--D
Potassium68is68a68severe68tissue68irritant.68The68safest68action68is68to68discontinue68the6
8solution68that68contains68the68potassium68and68discontinue68the68IV68altogether,68in68w
hich68case68the68client68would68need68another68site68started.68Assessing68for68a68blood6
8return68may68or68may68not68be68successful.68The68solution68could68be68diluted68(less68
potassium)68and68the68rate68could68be68slowed68once68it68is68determined68that68the68ne
edle68is68in68the68vein.
A68nurse68is68caring68for68an68older68adult68client68who68lives68alone.68Which68economic
68situation68presents68the68most68serious68problem68for68this68client?
a.68costs68of68creating68a68living68will
b.68stock68market68fluctuations
c.68increased68provider68benefits
d.68social68security68as68the68basis68of68income68-68answer--D
Older68adults68on68fixed68incomes68are68unable68to68adjust68their68income68to68meet68ris
ing68costs68associated68with68meeting68basic68needs
Controlling68pain68is68important68to68promoting68wellness.68Unrelieved68pain68has68been
68associated68with68
a.68prolonged68stress68response68and68a68cascade68of68harmful68effects68system68wide.
, b.68decreased68tumor68growth68and68longevity
c.68large68tidal68volumes68and68decreased68lung68capacity
d.68decreased68carbohydrate,68protein,68and68fat68destruction68-68answer--A
Pain68triggers68a68number68of68physiologic68stress68responses68in68the68human68body.68
Unrelieved68pain68can68prolong68the68stress68response68and68produce68a68cascade68of6
8harmful68effects68in68all68body68systems.68The68stress68response68causes68the68endocr
ine68system68to68release68excessive68amounts68of68hormones,68such68as68cortisol,68cat
echolamines,68and68glucagon.68Insulin68and68testosterone68levels68decrease.68Increase
d68endocrine68activity68in68turn68initiates68a68number68of68metabolic68processes,68in68par
ticular,68accelerated68carbohydrate,68protein,68and68fat68destruction,68whcih68can68result
68in68weight68loss,68tachycardia,68increased68respiratory68rate,68shock,68and68even68dea
th.68The68immune68system68is68also68affected68by68pain68as68demonstrated68by68resear
ch68showing68a68link68between68unrelieved68pain68and68a68higher68incidence68of68nosoc
omial68infections68and68increased68tumor68growth.68Large68tidal68volumes68are68not68as
sociated68with68pain68while68decreased68lung68capacity68is68associated68with68unrelieve
d68pain.68Decreased68tumor68growth68and68longevity68are68not68associated68with68unreli
eved68pain.68Decreased68carbs,68protein,68and68fat68are68not68associated68with68pain68o
r68stress68response.
Which68intervention68in68a68client68with68dehydration68induced68confusion68is68most68like
ly68to68relieve68the68confusion?
a.68increasing68the68IV68flow68rate68to6825068mL/hr
b.68applying68oxygen68by68mask68or68nasal68cannula
c.68placing68the68client68in68a68high68Fowler's68position
d.68Measuring68intake68and68output68every68four68hours68-68answer--A
Dehydration68most68frequently68leads68to68poor68cerebra68perfusion68and68cerebral68hyp
oxia,68causing68confusion.68Applying68oxygen68can68reduce68confusion,68even68if68perfu
sion68is68still68less68than68optimum.68Increasing68the68IV68flow68rate68would68increase68p
erfusion.68However,68depending68on68the68degree68of68dehydration,68rehydrating68the68
person68too68rapidly68with68IV68fluids68can68lead68to68cerebral68edema.
Which68client68is68at68greatest68risk68for68dehydration?
a.68younger68adult68client68on68bedrest
b.68older68adult68client68receiving68hypotonic68IV68fluid
c.68older68adult68client68with68cognitive68impairment
d.68younger68adult68client68receiving68hypertonic68IV68fluid68-68answer--C
Older68adults,68because68they68have68less68total68body68water68than68younger68adults,68
are68at68greater68risk68for68development68of68dehydration.68Anyone68who68is68cognitivel
y68impaired68and68cannot68obtain68fluids68independently68or68cannot68make68his68or68he
r68need68for68fluids68known68is68at68high68risk68for68dehydration
A68nurse68is68caring68for68several68clients.68Which68client68does68the68nurse68assess68m
ost68carefully68for68hyperkalemia?
TEST-EXAM TEST BANK FOR
MEDICAL SURGICAL NURSING 11TH
EDITION IGNATAVICIUS
The68nurse68is68assessing68a68group68of68clients.68Which68clients68are68at68greater68risk
68for68hypothermia68or68frostbite?68(select68all68that68apply)
a.68an68older68woman68with68hypertension
b.68a68young68man68with68a68body68mass68index68of6842
c.68a68young68many68who68has68just68consumed68six68martinis
d.68an68older68man68who68smokes68a68pack68of68cigarettes68a68day
e.68a68young68woman68who68is68anorexic
f.68a68young68woman68who68is68diabetic68-68answer--C,68D,68E,68F
clients68with68poor68nutrition,68fatigue,68and68multiple68chronic68illnesses68are68at68great
er68risk68for68hypothermia.68Clients68who68smoke,68consume68alcohol,68or68have68impair
ed68peripheral68circulation68have68a68higher68incidence68of68frostbite.
The68nurse68is68caring68for68four68clients.68Which68client68assessment68is68the68most68in
dicative68of68having68pain?
A)68Client68stating68that68he68is68"anxious"
B)68Heart68rate68of6810568beats/min68and68restlessness
C)68Blood68pressure68150/7068mm68Hg68and68sleeping
D)68Postoperative68client68with68a68neck68incision68-68answer--B
At68times68clients68are68unable68to68verbalize68that68they68are68in68pain68but68there68are
68indicators68that68the68client68may68have68acute68pain68such68as68increased68heart68rat
e,68increased68blood68pressure,68increased68respirations,68sweating,68restlessness,68an
d68overall68distress.68All68the68other68distractors68could68indicate68clients68who68have68t
he68potential68for68being68in68pain,68but68restlessness68with68tachycardia68is68the68most6
8indicative.
,When68describing68patient68education68approaches,68the68nurse68educator68would68expl
ain68that68informal68teaching68is68an68approach68that
a.68follows68formalized68plans
b.68has68standardized68content
c.68often68occurs68one-to-one
d.68addresses68group68needs68-68answer--
C.68Informal68teaching68is68individualized68one68on68one68teaching68which68represents68
the68majority68of68patient68education68done68by68nurses68that68occurs68when68an68interv
ention68is68explained68or68a68question68is68answered.68Group68needs68are68often68the68f
ocus68of68formal68patient68education68courses68or68classes.68Informal68teaching68does68
not68necessarily68follow68a68specific68formalized68plan.68It68may68be68planned68with68sp
ecific68content,68but68it68is68individualized68responses68to68patient68needs.68Formal68tea
ching68involves68the68use68of68a68curriculum/course68plan68with68standardized68content.
A68patient68expresses68a68strong68interest68in68returning68to68their68work,68family,68and68
hobbies68after68having68a68stroke.68Which68theory68type68would68the68nurse68use68to68d
evelop68a68plan68of68care68for68the68best68results68of68this68patient's68motivation68style?
a.68field
b.68biological
c.68cognitive
d.68sociologic68-68answer--
C.68Cognitive68theorists68believe68that68attention,68relevance,68confidence,68and68satisfa
ction68(ARCS)68are68the68conditions68that,68when68integrated,68motivate68someone68to68
learn.68Field68theorists68place68significance68on68how68achievement,68power,68the68need
68for68affiliation,68and68avoidance68motives68influence68individual68behavior.68Sociologic6
8theories68are68not68involved68in68motivation.
Which68statement68made68by68a68nurse68represents68the68need68for68further68education
68regarding68pain68management68in68older68adult68clients?
a.68older68adults68tend68to68report68pain68less68often68than68younger68adults
b.68older68clients68usually68have68more68experience68with68pain68than68younger68clients
c.68older68adults68are68at68greatest68risk68for68under68treated68pain
d.68older68clients68have68a68different68pain68mechanism68and68do68not68feel68it68as68muc
h68-68answer--D
There68is68no68evidence68to68support68the68idea68that68older68adult68clients68perceive68p
ain68any68differently68than68younger68clients.68The68other68statements68are68accurate68r
egarding68older68clients68and68pain.
The68nurse68is68working68at68a68first68aid68booth68for68a68spring68training68game68on68a6
8hot68day.68A68spectator68comes68in,68reporting68that68he68is68not68feeling68well.68Vital68
signs68are68temp68104.168F,68pulse6813268BPM,68respirs682668breaths/
,min,68and68blood68pressure68106/6668mm68Hg.68He68trips68over68his68feet68as68the68nur
se68leads68him68to68a68cot.68What68is68the68priory68action68of68the68nurse?
a.68admin68tylenol6865068mg68orally
b.68encourage68rest,68and68reassess68in681568minutes
c.68sponge68the68victim68with68cool68water68and68remove68his68shirt
d.68encourage68drinking68of68cool68water68or68sports68drink68-68answer--C
The68spectator68shows68signs68of68heat68stroke,68which68is68a68medical68emergency.68T
he68spectator68should68be68transported68to68the68ED68ASAP.68The68nurs68should68take6
8actions68to68lower68his68body68temp68in68teh68meantime68by68removing68his68shirt68and
68sponging68his68body68with68cool68water.68Lowering68body68temp68by68drinking68cool68fl
uids68or68taking68acetaminophen68is68not68as68effective68in68an68emergency68situation.68
The68client68needs68to68be68cooled68quickly68and68is68a68priority68for68treatment
The68client68is68receiving68an68IV68of686068mEq68of68potassium68chloride68ina68100068m
L68solution68of68dextrose685%68in680.45%68saline.68The68client68states68that68the68area68
around68the68IV68site68burns.68What68intervention68does68the68nurse68perform68first?
a.68assess68for68a68blood68return
b.68notify68the68physician
c.68document68the68finding
d.68stop68the68IV68infusion68-68answer--D
Potassium68is68a68severe68tissue68irritant.68The68safest68action68is68to68discontinue68the6
8solution68that68contains68the68potassium68and68discontinue68the68IV68altogether,68in68w
hich68case68the68client68would68need68another68site68started.68Assessing68for68a68blood6
8return68may68or68may68not68be68successful.68The68solution68could68be68diluted68(less68
potassium)68and68the68rate68could68be68slowed68once68it68is68determined68that68the68ne
edle68is68in68the68vein.
A68nurse68is68caring68for68an68older68adult68client68who68lives68alone.68Which68economic
68situation68presents68the68most68serious68problem68for68this68client?
a.68costs68of68creating68a68living68will
b.68stock68market68fluctuations
c.68increased68provider68benefits
d.68social68security68as68the68basis68of68income68-68answer--D
Older68adults68on68fixed68incomes68are68unable68to68adjust68their68income68to68meet68ris
ing68costs68associated68with68meeting68basic68needs
Controlling68pain68is68important68to68promoting68wellness.68Unrelieved68pain68has68been
68associated68with68
a.68prolonged68stress68response68and68a68cascade68of68harmful68effects68system68wide.
, b.68decreased68tumor68growth68and68longevity
c.68large68tidal68volumes68and68decreased68lung68capacity
d.68decreased68carbohydrate,68protein,68and68fat68destruction68-68answer--A
Pain68triggers68a68number68of68physiologic68stress68responses68in68the68human68body.68
Unrelieved68pain68can68prolong68the68stress68response68and68produce68a68cascade68of6
8harmful68effects68in68all68body68systems.68The68stress68response68causes68the68endocr
ine68system68to68release68excessive68amounts68of68hormones,68such68as68cortisol,68cat
echolamines,68and68glucagon.68Insulin68and68testosterone68levels68decrease.68Increase
d68endocrine68activity68in68turn68initiates68a68number68of68metabolic68processes,68in68par
ticular,68accelerated68carbohydrate,68protein,68and68fat68destruction,68whcih68can68result
68in68weight68loss,68tachycardia,68increased68respiratory68rate,68shock,68and68even68dea
th.68The68immune68system68is68also68affected68by68pain68as68demonstrated68by68resear
ch68showing68a68link68between68unrelieved68pain68and68a68higher68incidence68of68nosoc
omial68infections68and68increased68tumor68growth.68Large68tidal68volumes68are68not68as
sociated68with68pain68while68decreased68lung68capacity68is68associated68with68unrelieve
d68pain.68Decreased68tumor68growth68and68longevity68are68not68associated68with68unreli
eved68pain.68Decreased68carbs,68protein,68and68fat68are68not68associated68with68pain68o
r68stress68response.
Which68intervention68in68a68client68with68dehydration68induced68confusion68is68most68like
ly68to68relieve68the68confusion?
a.68increasing68the68IV68flow68rate68to6825068mL/hr
b.68applying68oxygen68by68mask68or68nasal68cannula
c.68placing68the68client68in68a68high68Fowler's68position
d.68Measuring68intake68and68output68every68four68hours68-68answer--A
Dehydration68most68frequently68leads68to68poor68cerebra68perfusion68and68cerebral68hyp
oxia,68causing68confusion.68Applying68oxygen68can68reduce68confusion,68even68if68perfu
sion68is68still68less68than68optimum.68Increasing68the68IV68flow68rate68would68increase68p
erfusion.68However,68depending68on68the68degree68of68dehydration,68rehydrating68the68
person68too68rapidly68with68IV68fluids68can68lead68to68cerebral68edema.
Which68client68is68at68greatest68risk68for68dehydration?
a.68younger68adult68client68on68bedrest
b.68older68adult68client68receiving68hypotonic68IV68fluid
c.68older68adult68client68with68cognitive68impairment
d.68younger68adult68client68receiving68hypertonic68IV68fluid68-68answer--C
Older68adults,68because68they68have68less68total68body68water68than68younger68adults,68
are68at68greater68risk68for68development68of68dehydration.68Anyone68who68is68cognitivel
y68impaired68and68cannot68obtain68fluids68independently68or68cannot68make68his68or68he
r68need68for68fluids68known68is68at68high68risk68for68dehydration
A68nurse68is68caring68for68several68clients.68Which68client68does68the68nurse68assess68m
ost68carefully68for68hyperkalemia?
