HESI - Medical Surgical
Nursing test-Exam TEST
BANK FOR MEDICAL
SURGICAL NURSING
11TH EDITION
IGNATAVICIUS
,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 ANSWERS-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.
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 - CORRECT ANSWERS-B
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.
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 ANSWERS-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 ANSWERS-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.
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
ANSWERS-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 ANSWERS-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 ANSWERS-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 ANSWERS-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 ANSWERS-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
Nursing test-Exam TEST
BANK FOR MEDICAL
SURGICAL NURSING
11TH EDITION
IGNATAVICIUS
,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 ANSWERS-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.
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 - CORRECT ANSWERS-B
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.
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 ANSWERS-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 ANSWERS-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.
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
ANSWERS-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 ANSWERS-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 ANSWERS-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 ANSWERS-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 ANSWERS-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
