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HESI RN MEDICAL SURGICAL NEWEST
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HESI RN MEDICAL SURGICAL NEWEST
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Medical-Surgical Nursing: Assessment and Management of Clinical Problems 9th Edition By Sharon Lewis, Shannon Dirksen, Margaret Heitkemper, Linda Bucher 9780323086783 Chapter 1-69 Complete Guide .
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Medical-Surgical Nursing: Assessment and Management of Clinical Problems 9th Edition By Sharon Lewis, Shannon Dirksen, Margaret Heitkemper, Linda Bucher 9780323086783 Chapter 1-69 Complete Guide .
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HESI RN MEDICAL SURGICAL NEWEST ACTUAL EXAM TESTBANK
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.
,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 - ANSWER: 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 - ANSWER: 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 - ANSWER: 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
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.
d. I will weigh myself each morning before I eat or drink. - ANSWER: D
Because 1 L of water weighs 1 kg, change in body weight is a good measure of excess
fluid loss or fluid retention. Weight loss greater than 0.5 lb daily is indicative of
excessive fluid loss. The other statements are not indicative of practices that will
prevent dehydration.
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