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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
✓ 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?
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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
✓ 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
✓ 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.
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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
✓ 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
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✓ 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
✓ 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?
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