HESI Medical Surgical Nursing

HESI Medical Surgical Nursing 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. 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. 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 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 d. Measuring intake and output every four hours - CORRECT ANSWER ===A Dehydration most frequently leads to poor c