TEST BANK FOR MEDICAL SURGICAL
NURSING 11TH EDITION IGNATAVICIUS
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
NURSING 11TH EDITION IGNATAVICIUS
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
