HESI - MEDICAL SURGICAL NURSING ACTUAL EXAM
ALLQUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES ALREADY GRADED A
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.
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.
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.
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.
,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
d. Measuring intake and output every four hours - answer-A
Dehydration most frequently leads to poor cerebra perfusion and cerebral hypoxia, causing
confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimum.
Increasing the IV flow rate would increase perfusion. However, depending on the degree of
dehydration, rehydrating the person too rapidly with IV fluids can lead to cerebral edema.
Which client is at greatest risk for dehydration?
a. younger adult client on bedrest
b. older adult client receiving hypotonic IV fluid
c. older adult client with cognitive impairment
d. younger adult client receiving hypertonic IV fluid - answer-C
Older adults, because they have less total body water than younger adults, are at greater risk
for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids
independently or cannot make his or her need for fluids known is at high risk for dehydration
A nurse is caring for several clients. Which client does the nurse assess most carefully for
hyperkalemia?
a. client with type 2 diabetes taking an oral anti-diabetic agent
, b. client with heart failure using a salt substitute
c. client taking a thiazide diuretic for hypertension
d. client taking non-steroidal anti-inflammatory drugs daily - answer-B
Many salt substitutes are composed of potassium chloride. Heavy use cna contribute to the
development of hyperkalemia. The client should be taught to read labels and to choose a salt
substitute that does not contain potassium. NSAIDs promote the retention of sodium but not
potassium.
An older adult client presents with signs and symptoms related to dig toxicity. Which age related
change may have contributed to this problem?
a. decreased renal blood flow
b. increased gastrointestinal motility
c. decreased ratio of adipose tissue to lean body mass
d. increased total body water - answer-A
Decreased renal blood flow and reduced glomerular filtration can result in slower medication
excretion time, potentially leading to toxic drug accumulation. Aging results in decreased total
body water and gastrointestinal motility and an increase in the ratio of adipose tissue to lean
body mass, but is not related to dig toxicity.
A client is being treated for dehydration. Which statement made by the client indicates
understanding of this condition?
a. I will use a salt substitute when making and eating my meals.
b. I must drink a quart of water or other liquid each day.
c. I will not drink liquids after 6 PM so I won't have to get up at night.
ALLQUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES ALREADY GRADED A
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.
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.
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.
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.
,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
d. Measuring intake and output every four hours - answer-A
Dehydration most frequently leads to poor cerebra perfusion and cerebral hypoxia, causing
confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimum.
Increasing the IV flow rate would increase perfusion. However, depending on the degree of
dehydration, rehydrating the person too rapidly with IV fluids can lead to cerebral edema.
Which client is at greatest risk for dehydration?
a. younger adult client on bedrest
b. older adult client receiving hypotonic IV fluid
c. older adult client with cognitive impairment
d. younger adult client receiving hypertonic IV fluid - answer-C
Older adults, because they have less total body water than younger adults, are at greater risk
for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids
independently or cannot make his or her need for fluids known is at high risk for dehydration
A nurse is caring for several clients. Which client does the nurse assess most carefully for
hyperkalemia?
a. client with type 2 diabetes taking an oral anti-diabetic agent
, b. client with heart failure using a salt substitute
c. client taking a thiazide diuretic for hypertension
d. client taking non-steroidal anti-inflammatory drugs daily - answer-B
Many salt substitutes are composed of potassium chloride. Heavy use cna contribute to the
development of hyperkalemia. The client should be taught to read labels and to choose a salt
substitute that does not contain potassium. NSAIDs promote the retention of sodium but not
potassium.
An older adult client presents with signs and symptoms related to dig toxicity. Which age related
change may have contributed to this problem?
a. decreased renal blood flow
b. increased gastrointestinal motility
c. decreased ratio of adipose tissue to lean body mass
d. increased total body water - answer-A
Decreased renal blood flow and reduced glomerular filtration can result in slower medication
excretion time, potentially leading to toxic drug accumulation. Aging results in decreased total
body water and gastrointestinal motility and an increase in the ratio of adipose tissue to lean
body mass, but is not related to dig toxicity.
A client is being treated for dehydration. Which statement made by the client indicates
understanding of this condition?
a. I will use a salt substitute when making and eating my meals.
b. I must drink a quart of water or other liquid each day.
c. I will not drink liquids after 6 PM so I won't have to get up at night.
