HESI - Medical Surgical Nursing test-Exam TEST BANK FOR MEDICAL SURGICAL NURSING 11TH EDITION

HESI - Medical Surgical Nursing test-Exam TEST BANK FOR MEDICAL SURGICAL NURSING 11TH EDITION 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 - ANS-C, D, E, F RATIONALE- 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 - ANS-B RATIONALE- 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. The nurse is assessing clients on a cardiac unit. Which client does the nurse assess most carefully for developing left-sided heart failure? A) Middle-aged woman with aortic stenosis B) Older woman who smokes cigarettes daily C) Older man who has had a myocardial infarction D) Middle-aged man with pulmonary hypertension - ANS-A RATIONALE- Although most people with heart failure will have failure that progresses from left to right, it is possible to have left-sided failure alone for a short period. It is also possible to have heart failure that progresses from right to left. Causes of left ventricular failure include mitral or aortic valve disease, coronary artery disease (CAD), and hypertension. 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 - ANS-C. RATIONALE- 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 - ANS-C RATIONALE- 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.