Medical Surgical Nursing 11th Edition by
Ignatavicius Test Bank 2025
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 - 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 - 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.
,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 - 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.
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
- 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 - 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 - 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 - 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 - 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 turn initiates a 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 dehydration induced confusion is most
likely to relieve the confusion?
a. increasing the IV flow rate to 250 mL/hr
b. applying oxygen by mask or nasal cannula
c. placing the client in a high Fowler's position
Ignatavicius Test Bank 2025
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 - 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 - 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.
,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 - 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.
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
- 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 - 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 - 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 - 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 - 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 turn initiates a 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 dehydration induced confusion is most
likely to relieve the confusion?
a. increasing the IV flow rate to 250 mL/hr
b. applying oxygen by mask or nasal cannula
c. placing the client in a high Fowler's position
