HESI - MEDICAL SURGICAL NURSING
TEST-EXAM TEST BANK FOR
MEDICAL SURGICAL NURSING 11TH
EDITION IGNATAVICIUS QUESTIONS
AND ANSWERS
The17nurse17is17assessing17a17group17of17clients.17Which17clients17are17at17greater17risk
17for17hypothermia17or17frostbite?17(select17all17that17apply)
a.17an17older17woman17with17hypertension
b.17a17young17man17with17a17body17mass17index17of1742
c.17a17young17many17who17has17just17consumed17six17martinis
d.17an17older17man17who17smokes17a17pack17of17cigarettes17a17day
e.17a17young17woman17who17is17anorexic
f.17a17young17woman17who17is17diabetic17-17C,17D,17E,17F
clients17with17poor17nutrition,17fatigue,17and17multiple17chronic17illnesses17are17at17great
er17risk17for17hypothermia.17Clients17who17smoke,17consume17alcohol,17or17have17impair
ed17peripheral17circulation17have17a17higher17incidence17of17frostbite.
The17nurse17is17caring17for17four17clients.17Which17client17assessment17is17the17most17in
dicative17of17having17pain?
A)17Client17stating17that17he17is17"anxious"
B)17Heart17rate17of1710517beats/min17and17restlessness
C)17Blood17pressure17150/7017mm17Hg17and17sleeping
D)17Postoperative17client17with17a17neck17incision17-17B
At17times17clients17are17unable17to17verbalize17that17they17are17in17pain17but17there17are
17indicators17that17the17client17may17have17acute17pain17such17as17increased17heart17rat
e,17increased17blood17pressure,17increased17respirations,17sweating,17restlessness,17an
d17overall17distress.17All17the17other17distractors17could17indicate17clients17who17have17t
he17potential17for17being17in17pain,17but17restlessness17with17tachycardia17is17the17most1
7indicative.
When17describing17patient17education17approaches,17the17nurse17educator17would17expl
ain17that17informal17teaching17is17an17approach17that
,a.17follows17formalized17plans
b.17has17standardized17content
c.17often17occurs17one-to-one
d.17addresses17group17needs17-
17C.17Informal17teaching17is17individualized17one17on17one17teaching17which17represents
17the17majority17of17patient17education17done17by17nurses17that17occurs17when17an17inte
rvention17is17explained17or17a17question17is17answered.17Group17needs17are17often17the1
7focus17of17formal17patient17education17courses17or17classes.17Informal17teaching17does
17not17necessarily17follow17a17specific17formalized17plan.17It17may17be17planned17with17s
pecific17content,17but17it17is17individualized17responses17to17patient17needs.17Formal17te
aching17involves17the17use17of17a17curriculum/
course17plan17with17standardized17content.
A17patient17expresses17a17strong17interest17in17returning17to17their17work,17family,17and17
hobbies17after17having17a17stroke.17Which17theory17type17would17the17nurse17use17to17d
evelop17a17plan17of17care17for17the17best17results17of17this17patient's17motivation17style?
a.17field
b.17biological
c.17cognitive
d.17sociologic17-
17C.17Cognitive17theorists17believe17that17attention,17relevance,17confidence,17and17satis
faction17(ARCS)17are17the17conditions17that,17when17integrated,17motivate17someone17to
17learn.17Field17theorists17place17significance17on17how17achievement,17power,17the17ne
ed17for17affiliation,17and17avoidance17motives17influence17individual17behavior.17Sociolog
ic17theories17are17not17involved17in17motivation.
Which17statement17made17by17a17nurse17represents17the17need17for17further17education
17regarding17pain17management17in17older17adult17clients?
a.17older17adults17tend17to17report17pain17less17often17than17younger17adults
b.17older17clients17usually17have17more17experience17with17pain17than17younger17clients
c.17older17adults17are17at17greatest17risk17for17under17treated17pain
d.17older17clients17have17a17different17pain17mechanism17and17do17not17feel17it17as17muc
h17-17D
There17is17no17evidence17to17support17the17idea17that17older17adult17clients17perceive17p
ain17any17differently17than17younger17clients.17The17other17statements17are17accurate17r
egarding17older17clients17and17pain.
The17nurse17is17working17at17a17first17aid17booth17for17a17spring17training17game17on17a1
7hot17day.17A17spectator17comes17in,17reporting17that17he17is17not17feeling17well.17Vital17
signs17are17temp17104.117F,17pulse1713217BPM,17respirs172617breaths/
min,17and17blood17pressure17106/6617mm17Hg.17He17trips17over17his17feet17as17the17nur
se17leads17him17to17a17cot.17What17is17the17priory17action17of17the17nurse?
,a.17admin17tylenol1765017mg17orally
b.17encourage17rest,17and17reassess17in171517minutes
c.17sponge17the17victim17with17cool17water17and17remove17his17shirt
d.17encourage17drinking17of17cool17water17or17sports17drink17-17C
The17spectator17shows17signs17of17heat17stroke,17which17is17a17medical17emergency.17T
he17spectator17should17be17transported17to17the17ED17ASAP.17The17nurs17should17take1
7actions17to17lower17his17body17temp17in17teh17meantime17by17removing17his17shirt17and
17sponging17his17body17with17cool17water.17Lowering17body17temp17by17drinking17cool17fl
uids17or17taking17acetaminophen17is17not17as17effective17in17an17emergency17situation.17
The17client17needs17to17be17cooled17quickly17and17is17a17priority17for17treatment
The17client17is17receiving17an17IV17of176017mEq17of17potassium17chloride17ina17100017m
L17solution17of17dextrose175%17in170.45%17saline.17The17client17states17that17the17area17
around17the17IV17site17burns.17What17intervention17does17the17nurse17perform17first?
a.17assess17for17a17blood17return
b.17notify17the17physician
c.17document17the17finding
d.17stop17the17IV17infusion17-17D
Potassium17is17a17severe17tissue17irritant.17The17safest17action17is17to17discontinue17the1
7solution17that17contains17the17potassium17and17discontinue17the17IV17altogether,17in17w
hich17case17the17client17would17need17another17site17started.17Assessing17for17a17blood1
7return17may17or17may17not17be17successful.17The17solution17could17be17diluted17(less17
potassium)17and17the17rate17could17be17slowed17once17it17is17determined17that17the17ne
edle17is17in17the17vein.
A17nurse17is17caring17for17an17older17adult17client17who17lives17alone.17Which17economic
17situation17presents17the17most17serious17problem17for17this17client?
a.17costs17of17creating17a17living17will
b.17stock17market17fluctuations
c.17increased17provider17benefits
d.17social17security17as17the17basis17of17income17-17D
Older17adults17on17fixed17incomes17are17unable17to17adjust17their17income17to17meet17ris
ing17costs17associated17with17meeting17basic17needs
Controlling17pain17is17important17to17promoting17wellness.17Unrelieved17pain17has17been
17associated17with17
a.17prolonged17stress17response17and17a17cascade17of17harmful17effects17system17wide.
b.17decreased17tumor17growth17and17longevity
c.17large17tidal17volumes17and17decreased17lung17capacity
, d.17decreased17carbohydrate,17protein,17and17fat17destruction17-17A
Pain17triggers17a17number17of17physiologic17stress17responses17in17the17human17body.17
Unrelieved17pain17can17prolong17the17stress17response17and17produce17a17cascade17of1
7harmful17effects17in17all17body17systems.17The17stress17response17causes17the17endocr
ine17system17to17release17excessive17amounts17of17hormones,17such17as17cortisol,17cat
echolamines,17and17glucagon.17Insulin17and17testosterone17levels17decrease.17Increase
d17endocrine17activity17in17turn17initiates17a17number17of17metabolic17processes,17in17par
ticular,17accelerated17carbohydrate,17protein,17and17fat17destruction,17whcih17can17result
17in17weight17loss,17tachycardia,17increased17respiratory17rate,17shock,17and17even17dea
th.17The17immune17system17is17also17affected17by17pain17as17demonstrated17by17resear
ch17showing17a17link17between17unrelieved17pain17and17a17higher17incidence17of17nosoc
omial17infections17and17increased17tumor17growth.17Large17tidal17volumes17are17not17as
sociated17with17pain17while17decreased17lung17capacity17is17associated17with17unrelieve
d17pain.17Decreased17tumor17growth17and17longevity17are17not17associated17with17unreli
eved17pain.17Decreased17carbs,17protein,17and17fat17are17not17associated17with17pain17o
r17stress17response.
Which17intervention17in17a17client17with17dehydration17induced17confusion17is17most17like
ly17to17relieve17the17confusion?
a.17increasing17the17IV17flow17rate17to1725017mL/hr
b.17applying17oxygen17by17mask17or17nasal17cannula
c.17placing17the17client17in17a17high17Fowler's17position
d.17Measuring17intake17and17output17every17four17hours17-17A
Dehydration17most17frequently17leads17to17poor17cerebra17perfusion17and17cerebral17hyp
oxia,17causing17confusion.17Applying17oxygen17can17reduce17confusion,17even17if17perfu
sion17is17still17less17than17optimum.17Increasing17the17IV17flow17rate17would17increase17p
erfusion.17However,17depending17on17the17degree17of17dehydration,17rehydrating17the17
person17too17rapidly17with17IV17fluids17can17lead17to17cerebral17edema.
Which17client17is17at17greatest17risk17for17dehydration?
a.17younger17adult17client17on17bedrest
b.17older17adult17client17receiving17hypotonic17IV17fluid
c.17older17adult17client17with17cognitive17impairment
d.17younger17adult17client17receiving17hypertonic17IV17fluid17-17C
Older17adults,17because17they17have17less17total17body17water17than17younger17adults,17
are17at17greater17risk17for17development17of17dehydration.17Anyone17who17is17cognitivel
y17impaired17and17cannot17obtain17fluids17independently17or17cannot17make17his17or17he
r17need17for17fluids17known17is17at17high17risk17for17dehydration
A17nurse17is17caring17for17several17clients.17Which17client17does17the17nurse17assess17m
ost17carefully17for17hyperkalemia?
a.17client17with17type17217diabetes17taking17an17oral17anti-diabetic17agent
TEST-EXAM TEST BANK FOR
MEDICAL SURGICAL NURSING 11TH
EDITION IGNATAVICIUS QUESTIONS
AND ANSWERS
The17nurse17is17assessing17a17group17of17clients.17Which17clients17are17at17greater17risk
17for17hypothermia17or17frostbite?17(select17all17that17apply)
a.17an17older17woman17with17hypertension
b.17a17young17man17with17a17body17mass17index17of1742
c.17a17young17many17who17has17just17consumed17six17martinis
d.17an17older17man17who17smokes17a17pack17of17cigarettes17a17day
e.17a17young17woman17who17is17anorexic
f.17a17young17woman17who17is17diabetic17-17C,17D,17E,17F
clients17with17poor17nutrition,17fatigue,17and17multiple17chronic17illnesses17are17at17great
er17risk17for17hypothermia.17Clients17who17smoke,17consume17alcohol,17or17have17impair
ed17peripheral17circulation17have17a17higher17incidence17of17frostbite.
The17nurse17is17caring17for17four17clients.17Which17client17assessment17is17the17most17in
dicative17of17having17pain?
A)17Client17stating17that17he17is17"anxious"
B)17Heart17rate17of1710517beats/min17and17restlessness
C)17Blood17pressure17150/7017mm17Hg17and17sleeping
D)17Postoperative17client17with17a17neck17incision17-17B
At17times17clients17are17unable17to17verbalize17that17they17are17in17pain17but17there17are
17indicators17that17the17client17may17have17acute17pain17such17as17increased17heart17rat
e,17increased17blood17pressure,17increased17respirations,17sweating,17restlessness,17an
d17overall17distress.17All17the17other17distractors17could17indicate17clients17who17have17t
he17potential17for17being17in17pain,17but17restlessness17with17tachycardia17is17the17most1
7indicative.
When17describing17patient17education17approaches,17the17nurse17educator17would17expl
ain17that17informal17teaching17is17an17approach17that
,a.17follows17formalized17plans
b.17has17standardized17content
c.17often17occurs17one-to-one
d.17addresses17group17needs17-
17C.17Informal17teaching17is17individualized17one17on17one17teaching17which17represents
17the17majority17of17patient17education17done17by17nurses17that17occurs17when17an17inte
rvention17is17explained17or17a17question17is17answered.17Group17needs17are17often17the1
7focus17of17formal17patient17education17courses17or17classes.17Informal17teaching17does
17not17necessarily17follow17a17specific17formalized17plan.17It17may17be17planned17with17s
pecific17content,17but17it17is17individualized17responses17to17patient17needs.17Formal17te
aching17involves17the17use17of17a17curriculum/
course17plan17with17standardized17content.
A17patient17expresses17a17strong17interest17in17returning17to17their17work,17family,17and17
hobbies17after17having17a17stroke.17Which17theory17type17would17the17nurse17use17to17d
evelop17a17plan17of17care17for17the17best17results17of17this17patient's17motivation17style?
a.17field
b.17biological
c.17cognitive
d.17sociologic17-
17C.17Cognitive17theorists17believe17that17attention,17relevance,17confidence,17and17satis
faction17(ARCS)17are17the17conditions17that,17when17integrated,17motivate17someone17to
17learn.17Field17theorists17place17significance17on17how17achievement,17power,17the17ne
ed17for17affiliation,17and17avoidance17motives17influence17individual17behavior.17Sociolog
ic17theories17are17not17involved17in17motivation.
Which17statement17made17by17a17nurse17represents17the17need17for17further17education
17regarding17pain17management17in17older17adult17clients?
a.17older17adults17tend17to17report17pain17less17often17than17younger17adults
b.17older17clients17usually17have17more17experience17with17pain17than17younger17clients
c.17older17adults17are17at17greatest17risk17for17under17treated17pain
d.17older17clients17have17a17different17pain17mechanism17and17do17not17feel17it17as17muc
h17-17D
There17is17no17evidence17to17support17the17idea17that17older17adult17clients17perceive17p
ain17any17differently17than17younger17clients.17The17other17statements17are17accurate17r
egarding17older17clients17and17pain.
The17nurse17is17working17at17a17first17aid17booth17for17a17spring17training17game17on17a1
7hot17day.17A17spectator17comes17in,17reporting17that17he17is17not17feeling17well.17Vital17
signs17are17temp17104.117F,17pulse1713217BPM,17respirs172617breaths/
min,17and17blood17pressure17106/6617mm17Hg.17He17trips17over17his17feet17as17the17nur
se17leads17him17to17a17cot.17What17is17the17priory17action17of17the17nurse?
,a.17admin17tylenol1765017mg17orally
b.17encourage17rest,17and17reassess17in171517minutes
c.17sponge17the17victim17with17cool17water17and17remove17his17shirt
d.17encourage17drinking17of17cool17water17or17sports17drink17-17C
The17spectator17shows17signs17of17heat17stroke,17which17is17a17medical17emergency.17T
he17spectator17should17be17transported17to17the17ED17ASAP.17The17nurs17should17take1
7actions17to17lower17his17body17temp17in17teh17meantime17by17removing17his17shirt17and
17sponging17his17body17with17cool17water.17Lowering17body17temp17by17drinking17cool17fl
uids17or17taking17acetaminophen17is17not17as17effective17in17an17emergency17situation.17
The17client17needs17to17be17cooled17quickly17and17is17a17priority17for17treatment
The17client17is17receiving17an17IV17of176017mEq17of17potassium17chloride17ina17100017m
L17solution17of17dextrose175%17in170.45%17saline.17The17client17states17that17the17area17
around17the17IV17site17burns.17What17intervention17does17the17nurse17perform17first?
a.17assess17for17a17blood17return
b.17notify17the17physician
c.17document17the17finding
d.17stop17the17IV17infusion17-17D
Potassium17is17a17severe17tissue17irritant.17The17safest17action17is17to17discontinue17the1
7solution17that17contains17the17potassium17and17discontinue17the17IV17altogether,17in17w
hich17case17the17client17would17need17another17site17started.17Assessing17for17a17blood1
7return17may17or17may17not17be17successful.17The17solution17could17be17diluted17(less17
potassium)17and17the17rate17could17be17slowed17once17it17is17determined17that17the17ne
edle17is17in17the17vein.
A17nurse17is17caring17for17an17older17adult17client17who17lives17alone.17Which17economic
17situation17presents17the17most17serious17problem17for17this17client?
a.17costs17of17creating17a17living17will
b.17stock17market17fluctuations
c.17increased17provider17benefits
d.17social17security17as17the17basis17of17income17-17D
Older17adults17on17fixed17incomes17are17unable17to17adjust17their17income17to17meet17ris
ing17costs17associated17with17meeting17basic17needs
Controlling17pain17is17important17to17promoting17wellness.17Unrelieved17pain17has17been
17associated17with17
a.17prolonged17stress17response17and17a17cascade17of17harmful17effects17system17wide.
b.17decreased17tumor17growth17and17longevity
c.17large17tidal17volumes17and17decreased17lung17capacity
, d.17decreased17carbohydrate,17protein,17and17fat17destruction17-17A
Pain17triggers17a17number17of17physiologic17stress17responses17in17the17human17body.17
Unrelieved17pain17can17prolong17the17stress17response17and17produce17a17cascade17of1
7harmful17effects17in17all17body17systems.17The17stress17response17causes17the17endocr
ine17system17to17release17excessive17amounts17of17hormones,17such17as17cortisol,17cat
echolamines,17and17glucagon.17Insulin17and17testosterone17levels17decrease.17Increase
d17endocrine17activity17in17turn17initiates17a17number17of17metabolic17processes,17in17par
ticular,17accelerated17carbohydrate,17protein,17and17fat17destruction,17whcih17can17result
17in17weight17loss,17tachycardia,17increased17respiratory17rate,17shock,17and17even17dea
th.17The17immune17system17is17also17affected17by17pain17as17demonstrated17by17resear
ch17showing17a17link17between17unrelieved17pain17and17a17higher17incidence17of17nosoc
omial17infections17and17increased17tumor17growth.17Large17tidal17volumes17are17not17as
sociated17with17pain17while17decreased17lung17capacity17is17associated17with17unrelieve
d17pain.17Decreased17tumor17growth17and17longevity17are17not17associated17with17unreli
eved17pain.17Decreased17carbs,17protein,17and17fat17are17not17associated17with17pain17o
r17stress17response.
Which17intervention17in17a17client17with17dehydration17induced17confusion17is17most17like
ly17to17relieve17the17confusion?
a.17increasing17the17IV17flow17rate17to1725017mL/hr
b.17applying17oxygen17by17mask17or17nasal17cannula
c.17placing17the17client17in17a17high17Fowler's17position
d.17Measuring17intake17and17output17every17four17hours17-17A
Dehydration17most17frequently17leads17to17poor17cerebra17perfusion17and17cerebral17hyp
oxia,17causing17confusion.17Applying17oxygen17can17reduce17confusion,17even17if17perfu
sion17is17still17less17than17optimum.17Increasing17the17IV17flow17rate17would17increase17p
erfusion.17However,17depending17on17the17degree17of17dehydration,17rehydrating17the17
person17too17rapidly17with17IV17fluids17can17lead17to17cerebral17edema.
Which17client17is17at17greatest17risk17for17dehydration?
a.17younger17adult17client17on17bedrest
b.17older17adult17client17receiving17hypotonic17IV17fluid
c.17older17adult17client17with17cognitive17impairment
d.17younger17adult17client17receiving17hypertonic17IV17fluid17-17C
Older17adults,17because17they17have17less17total17body17water17than17younger17adults,17
are17at17greater17risk17for17development17of17dehydration.17Anyone17who17is17cognitivel
y17impaired17and17cannot17obtain17fluids17independently17or17cannot17make17his17or17he
r17need17for17fluids17known17is17at17high17risk17for17dehydration
A17nurse17is17caring17for17several17clients.17Which17client17does17the17nurse17assess17m
ost17carefully17for17hyperkalemia?
a.17client17with17type17217diabetes17taking17an17oral17anti-diabetic17agent
