HESI - Medical Surgical Nursing test
When describing pa ent educa on approaches, the nurse educator would explain that informal
teaching is an approach that
a. follows formalized plans
b. has standardized content
c. o en occurs one-to-one
d. addresses group needs - CORRECT ANSWER C. Informal teaching is individualized one
on one teaching which represents the majority of pa ent educa on done by nurses that occurs
when an interven on is explained or a ques on is answered. Group needs are o en the focus of
formal pa ent educa on 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 pa ent needs. Formal teaching involves the use of a curriculum/course plan with
standardized content.
A pa ent expresses a strong interest in returning to their work, family, and hobbies a er having
a stroke. Which theory type would the nurse use to develop a plan of care for the best results of
this pa ent's mo va on style?
a. field
b. biological
c. cogni ve
d. sociologic - CORRECT ANSWER C. Cogni ve theorists believe that a en on, relevance,
confidence, and sa sfac on (ARCS) are the condi ons that, when integrated, mo vate someone
to learn. Field theorists place significance on how achievement, power, the need for affilia on,
and avoidance mo ves influence individual behavior. Sociologic theories are not involved in
mo va on.
,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 mar nis
d. an older man who smokes a pack of cigare es a day
e. a young woman who is anorexic
f. a young woman who is diabe c - CORRECT ANSWER C, D, E, F
clients with poor nutri on, fa gue, and mul ple chronic illnesses are at greater risk for
hypothermia. Clients who smoke, consume alcohol, or have impaired peripheral circula on have
a higher incidence of frostbite.
Which statement made by a nurse represents the need for further educa on regarding pain
management in older adult clients?
a. older adults tend to report pain less o en 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, repor ng 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 ac on of the nurse?
a. admin tylenol 650 mg orally
b. encourage rest, and reassess in 15 minutes
c. sponge the vic m 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 ac ons to lower his body temp in teh
mean me by removing his shirt and sponging his body with cool water. Lowering body temp by
drinking cool fluids or taking acetaminophen is not as effec ve in an emergency situa on. 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 solu on of dextrose
5% in 0.45% saline. The client states that the area around the IV site burns. What interven on
does the nurse perform first?
a. assess for a blood return
b. no fy the physician
c. document the finding
d. stop the IV infusion - CORRECT ANSWER D
Potassium is a severe ssue irritant. The safest ac on is to discon nue the solu on that
contains the potassium and discon nue 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 solu on
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 situa on presents
the most serious problem for this client?
a. costs of crea ng a living will
b. stock market fluctua ons
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 mee ng basic needs
Controlling pain is important to promo ng 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 dal volumes and decreased lung capacity
d. decreased carbohydrate, protein, and fat destruc on - 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 cor sol, catecholamines, and glucagon. Insulin and testosterone levels decrease. Increased
endocrine ac vity in turn ini ates a number of metabolic processes, in par cular, accelerated
carbohydrate, protein, and fat destruc on, 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 infec ons and increased tumor growth. Large dal volumes are not associated with
pain while decreased lung capacity is associated with unrelieved pain. Decreased tumor growth
When describing pa ent educa on approaches, the nurse educator would explain that informal
teaching is an approach that
a. follows formalized plans
b. has standardized content
c. o en occurs one-to-one
d. addresses group needs - CORRECT ANSWER C. Informal teaching is individualized one
on one teaching which represents the majority of pa ent educa on done by nurses that occurs
when an interven on is explained or a ques on is answered. Group needs are o en the focus of
formal pa ent educa on 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 pa ent needs. Formal teaching involves the use of a curriculum/course plan with
standardized content.
A pa ent expresses a strong interest in returning to their work, family, and hobbies a er having
a stroke. Which theory type would the nurse use to develop a plan of care for the best results of
this pa ent's mo va on style?
a. field
b. biological
c. cogni ve
d. sociologic - CORRECT ANSWER C. Cogni ve theorists believe that a en on, relevance,
confidence, and sa sfac on (ARCS) are the condi ons that, when integrated, mo vate someone
to learn. Field theorists place significance on how achievement, power, the need for affilia on,
and avoidance mo ves influence individual behavior. Sociologic theories are not involved in
mo va on.
,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 mar nis
d. an older man who smokes a pack of cigare es a day
e. a young woman who is anorexic
f. a young woman who is diabe c - CORRECT ANSWER C, D, E, F
clients with poor nutri on, fa gue, and mul ple chronic illnesses are at greater risk for
hypothermia. Clients who smoke, consume alcohol, or have impaired peripheral circula on have
a higher incidence of frostbite.
Which statement made by a nurse represents the need for further educa on regarding pain
management in older adult clients?
a. older adults tend to report pain less o en 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, repor ng 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 ac on of the nurse?
a. admin tylenol 650 mg orally
b. encourage rest, and reassess in 15 minutes
c. sponge the vic m 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 ac ons to lower his body temp in teh
mean me by removing his shirt and sponging his body with cool water. Lowering body temp by
drinking cool fluids or taking acetaminophen is not as effec ve in an emergency situa on. 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 solu on of dextrose
5% in 0.45% saline. The client states that the area around the IV site burns. What interven on
does the nurse perform first?
a. assess for a blood return
b. no fy the physician
c. document the finding
d. stop the IV infusion - CORRECT ANSWER D
Potassium is a severe ssue irritant. The safest ac on is to discon nue the solu on that
contains the potassium and discon nue 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 solu on
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 situa on presents
the most serious problem for this client?
a. costs of crea ng a living will
b. stock market fluctua ons
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 mee ng basic needs
Controlling pain is important to promo ng 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 dal volumes and decreased lung capacity
d. decreased carbohydrate, protein, and fat destruc on - 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 cor sol, catecholamines, and glucagon. Insulin and testosterone levels decrease. Increased
endocrine ac vity in turn ini ates a number of metabolic processes, in par cular, accelerated
carbohydrate, protein, and fat destruc on, 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 infec ons and increased tumor growth. Large dal volumes are not associated with
pain while decreased lung capacity is associated with unrelieved pain. Decreased tumor growth
