HESI - Medical Surgical Nursing test-Exam TEST BANK FOR
MEDICAL SURGICAL NURSING 11TH EDITION
IGNATAVICIUS VERIFIED BY EXPERT 100% RATED A+
VERIFIED BY EXPERTS
The nursery nurse identifies a newborn at significant risk for hypothermic alteration in
thermoregulation because the patient is:
A) large for gestational age.
B) well nourished.
C) born at term.
D) low birth weight. - Answer-D
Low birth weight and poorly nourished infants (particularly premature infants) and children
are at greatest risk for hypothermia. A large for gestational age infant would not be
malnourished. An infant born at term is not considered at significant risk. A well nourished
infant is not at significant risk.
The nurse is assessing a patient's functional ability. Which activities most closely match the
definition of functional ability?
A) Healthy individual, college educated, travels frequently, can balance a checkbook
,B) Healthy individual, works out, reads well, cooks and cleans house
C) Healthy individual, volunteers at church, works part time, takes care of family and house
D) Healthy individual, works outside the home, uses a cane, well groomed - Answer-C
Functional ability refers to the individual's ability to perform the normal daily activities
required to meet basic needs; fulfill usual roles in the family, workplace, and community; and
maintain health and well-being. The other options are good; however, each option has
advanced or independent activities in the context of the option.
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.
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 - 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.
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.
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
MEDICAL SURGICAL NURSING 11TH EDITION
IGNATAVICIUS VERIFIED BY EXPERT 100% RATED A+
VERIFIED BY EXPERTS
The nursery nurse identifies a newborn at significant risk for hypothermic alteration in
thermoregulation because the patient is:
A) large for gestational age.
B) well nourished.
C) born at term.
D) low birth weight. - Answer-D
Low birth weight and poorly nourished infants (particularly premature infants) and children
are at greatest risk for hypothermia. A large for gestational age infant would not be
malnourished. An infant born at term is not considered at significant risk. A well nourished
infant is not at significant risk.
The nurse is assessing a patient's functional ability. Which activities most closely match the
definition of functional ability?
A) Healthy individual, college educated, travels frequently, can balance a checkbook
,B) Healthy individual, works out, reads well, cooks and cleans house
C) Healthy individual, volunteers at church, works part time, takes care of family and house
D) Healthy individual, works outside the home, uses a cane, well groomed - Answer-C
Functional ability refers to the individual's ability to perform the normal daily activities
required to meet basic needs; fulfill usual roles in the family, workplace, and community; and
maintain health and well-being. The other options are good; however, each option has
advanced or independent activities in the context of the option.
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.
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 - 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.
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.
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
