TEST BANK FOR MEDICAL SURGICAL NURSING 11TH
EDITION IGNATAVICIUS ALL CHAPTERS
During orientation to an emergency department, the nurse educator would
... [Show More] be
concerned if the new nurse listed which of the following as a risk factor for impaired
thermoregulation?
A) Temperature extremes
B) Occupational exposure
C) Impaired cognition
D) Physical agility - ANS-D
Physical agility is not a risk factor for impaired thermoregulation. The nurse educator
would use this information to plan additional teaching to include medical conditions and
gait disturbance as risk factors for hypothermia, because their bodies have a reduced
ability to generate heat. Impaired cognition is a risk factor. Recreational or occupational
exposure is a risk factor. Temperature extremes are risk factors for impaired
thermoregulation.
An older adult client is in physical restraints. Which intervention by the nurse is the
priority?
A) Assess the client hourly while keeping the restraints in place.
B) Assess the client once each shift, releasing the restraints for feeding.
C) Assess the client twice each shift while keeping the restraints in place.
D) Assess the client every 30 to 60 minutes, releasing restraints every 2 hours. - ANS-D
The application of restraints can have serious consequences. Thus, the nurse should
check the client every 30 to 60 minutes, releasing the restraints every 2 hours for
positioning and toileting. The other answers would not be appropriate because the client
would not be assessed frequently enough, and circulation to the limbs could be
compromised. Assessing every hour and releasing the restraints every 2 hours is in
compliance with federal policy for monitoring clients in restraints.
The nurse is assessing a client with a long-term history of arthritic pain. Assessment
reveals a heart rate of 115 beats/min and blood pressure of 170/80 mm Hg. Which
intervention will the nurse carry out first?
A) Administer blood pressure medication.
B) Administer a drug to lower the heart rate.
C) Continue to assess for possible causes of elevated vital signs.
D) Assess whether the client needs anti-arthritis medication. - ANS-C
Arthritis is categorized as chronic pain. With chronic pain, the body adapts by blocking
the sympathetic nervous system; this normally causes tachycardia and increased blood
pressure. Therefore, this client's high blood pressure and heart rate are not caused by
chronic pain and may be a result of a more acute type of pain. Therefore, the best
intervention is for the nurse to establish whether the client is having pain other than
arthritic pain, and then to decide which intervention should be carried out.
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 - ANS-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 - ANS-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 - ANS-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 adult [Show Less]