IGNATAVICIUS MEDICAL SURGICAL
NURSING EXAM SCRIPT VERIFIED
QUESTIONS AND SOLUTIONS COMPLETE
REVIEW MATERIAL
●● 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
Answer: 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
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
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.
●● 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
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
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
NURSING EXAM SCRIPT VERIFIED
QUESTIONS AND SOLUTIONS COMPLETE
REVIEW MATERIAL
●● 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
Answer: 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
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
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.
●● 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
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
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
