HESI - Medical Surgical Nursing test-Exam TEST BANK FOR MEDICAL SURGICAL NURSING 11TH EDITION IGNATAVICIUS EXAM QUESTIONS AND ANSWERS WITH RATIONALES ALREADY GRADED A+ 2022-2023 UPDATE

HESI - Medical Surgical Nursing
test-Exam TEST BANK FOR
MEDICAL SURGICAL NURSING
11TH EDITION IGNATAVICIUS
EXAM QUESTIONS AND ANSWERS
WITH RATIONALES ALREADY
GRADED A+ 2022-2023 UPDATE
Which is most indicative of pain in an older client who is
confused? (Select all that apply).
A) Screaming
B) Decreased blood pressure
C) Crying
D) Decreased respirations
E) Facial grimace
F) Restlessness - ANSWER-A,C,E,F
Rationale.No one scale has been found to be the best
tool to use in pain assessment for adults with cognitive
impairment. Facial expression, motor behavior, mood,
socialization, and vocalization are common indicators of
pain in cognitively impaired adults. In acute pain,
nonverbal indicators of pain could include increased
blood pressure and respirations.
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
Rationale.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
Rationale.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.
Which action demonstrates that the nurse understands
the purpose of the Rapid Response Team?
A) Documenting all changes observed in the client and
maintaining a postoperative flow sheet
B) Monitoring the client for changes in postoperative
status such as wound infection
C) Notifying the physician of the client's change in blood
pressure from 140 to 88 mm Hg systolic
D) Notifying the physician of the client's increase in
restlessness after medication change - ANSWER-C
Rationale.The Rapid Response Team (RRT) saves lives and
decreases the risk for harm by providing care to clients
before a respiratory or cardiac arrest occurs. Although
the RRT does not replace the Code Team, which responds
to client arrests, it intervenes rapidly for those who are
beginning to decline clinically. It would be appropriate
for the RRT to intervene when the client has experienced
a 52-point drop in blood pressure. Monitoring the client's
postoperative status, maintaining a postoperative flow
sheet, and notifying the physician of a change in the
client's status after a medication change would not be
considered activities of the Rapid Response Team