,Chapter01:ProfessionalNursingPracticeLewis:
.xi .xi .xi .xi .xi
Medical-SurgicalNursing,10thEdition a
b a
b
MULTIPLECHOICE
1. Thenursecompletesanadmissiondatabaseandexplainsthattheplanofcareanddischargegoals . x i
. willbedevelopedwiththepatient’sinput.Thepatientstates,“Howisthisdifferentfromwhatthe
x i ba ba .xi
doctordoes?”Whichresponsewouldbemostappropriateforthenursetomake?
.xi .xi .xi .xi
a. “Theroleofthenurseistoadministermedicationsand othertreatmentsprescribedby ba ba .xi
yourdoctor.” .xi
b. “Thenurse’sjobistohelpthedoctorbycollectinginformationand .xi ba
communicatinganyproblemsthatoccur.”
.xi
c. “Nursesperformmanyofthesameproceduresasthedoctor, but nurses arewiththe ba .xi ba ba ba .xi
patientsforalongertimethanthedoctor.”
.xi
d. “Inadditiontocaringforyouwhile youaresick,thenurseswillassist youto ba .xi ba ba
developanindividualizedplantomaintainyourhealth.”
.xi
ANS: D . x i
ThisresponseisconsistentwiththeAmericanNursesAssociation(ANA)definitionofnursing, .xi .xi .xi .xi
which describestheroleofnursesinpromotinghealth.Theotherresponsesdescribe someofthe
.xi ba .xi ba
dependent andcollaborative functionsofthenursing role butdonotaccuratelydescribethenurse’s
.xi ba .xi
. roleinthehealthcaresystem.
x i
DIF: CognitiveLevel:Understand(comprehension) ba ba REF: 3
TOP: NursingProcess: Implementation MSC: .xi . x i NCLEX:SafeandEffectiveCareEnvironment ba
2. Thenursedescribestoastudentnursehowtouseevidence-basedpracticeguidelineswhen
. x i caringforpatients.Whichstatement,ifmadebythenurse,wouldbethemost accurate? .xi .xi .xi .xi .xi .xi .xi
a. “Inferencesfrom clinicalresearchstudiesareusedasa guide.” ba .xi ba .xi ba ba
b. “Patientcareisbasedonclinicaljudgment,experience, and traditions.” .xi ba
c. “Data are evaluatedtoshowthatthepatientoutcomesareconsistentlymet.”
ba . x i ba
d. “Recommendationsarebasedonresearch,clinicalexpertise,andpatient ba ba ba ba ba
preferences.”
.xi
ANS: D . x i
Evidence-basedpractice(EBP)istheuseofthebestresearch-basedevidencecombinedwith .xi
.clinicianexpertise.Clinicaljudgmentbased onthenurse’sclinicalexperienceispartofEBP,but
x i ba ba ba ba .xi
clinical decisionmakingshouldalsoincorporate currentresearchandresearch-based guidelines.
.xi ba ba ba . x i
. Evaluationof patientoutcomesisimportant,but interventionsshould bebasedonresearchfrom
x i ba ba ba ba .xi
randomized controlstudieswithalargenumberofsubjects.
.xi ba
DIF: CognitiveLevel:Remember(knowledge) ba REF: 15
TOP: NursingProcess:Planning MSC: ba .xi . x i NCLEX:SafeandEffectiveCareEnvironment ba
3. Thenurseteachesastudentnurseabouthowtoapplythenursingprocesswhenproviding ba ba
patientcare. Whichstatement, ifmadebythestudentnurse,indicatesthatteachingwas
.xi .xi .xi
successful?
.xi
a. “Thenursingprocessisascientific-basedmethodofdiagnosingthepatient’s ba ba ba
healthcareproblems.” .xi
b. “Thenursing processisaproblem-solving toolused toidentifyandtreat patients’
ba ba .xi ba .xi ba ba
, healthcareneeds.” ba
c. “Thenursingprocessisusedprimarilytoexplainnursinginterventionstoother
ba ba ba ba ba
healthcareprofessionals.”
. x i
d. “Thenursingprocessisbasedonnursingtheorythatincorporatesthe ba ba ba ba ba
biopsychosocialnatureofhumans.”
.xi
ANS: B . x i
Thenursingprocessisaproblem-solvingapproachtotheidentificationandtreatmentofpatients’ ba . x i
. problems.Diagnosisisonlyonephaseofthenursingprocess.Theprimaryuseofthe
x i .xi ba
nursingprocess isinpatientcare,
.xi .xi
nottoestablishnursingtheoryorexplainnursing interventionstootherhealthcare
.xi ba
. professionals.
x i
DIF: CognitiveLevel:Understand(comprehension) ba REF: 5
TOP: NursingProcess: Implementation MSC: .xi . x i NCLEX:SafeandEffectiveCareEnvironment ba
4. Apatienthasbeenadmittedtothehospitalforsurgeryandtellsthenurse,“Idonotfeel ba ba . x i . x i
. x i comfortableleavingmychildrenwithmyparents.”Whichactionshouldthenursetakenext
ba ba ba ba ba ba
?
a. Reassurethepatient that thesefeelingsarecommonforparents. ba .xi
b. Havethepatientcallthe childrentoensurethat theyaredoingwell. .xi ba
c. Gathermoredataabout thepatient’sfeelingsaboutthechild-carearrangements. ba ba
d. Callthepatient’sparentstodeterminewhetheradequatechildcareisbeing
ba ba
provided.
.xi
ANS: C . x i
Becauseacompleteassessmentisnecessaryinordertoidentifyaproblemandchoosean ba ba . x i
. appropriateintervention,thenurse’sfirstactionshould be toobtainmoreinformation.Theother
x i .xi .xi .xi .xi ba .xi
actionsmaybeappropriate,butmoreassessmentisneeded beforethebestinterventioncanbe
.xi ba ba .xi
chosen.
.xi
DIF: CognitiveLevel:Apply(application) REF: 6
OBJ: SpecialQuestions:Prioritization .xi .xi TOP: NursingProcess:Assessment
. xi ba
MSC:.xi NCLEX:PsychosocialIntegrity . x i .xi .xi
5. Apatient whoisparalyzed ontheleftsideofthebodyafterastrokedevelops a pressure ulceronthe
ba ba ba .xi ba ba ba .xi
.xi lefthip.Which nursing diagnosisismostappropriate?
.xi ba .xi .xi
a. Impairedphysicalmobilityrelatedtoleft-sidedparalysis
b. Risk forimpaired tissueintegrityrelatedtoleft-sidedweakness
ba . x i
c. Impairedskinintegrityrelated toaltered circulationandpressure ba ba .xi
d. Ineffectivetissueperfusionrelatedtoinabilitytomoveindependently
ANS: C . x i
Thepatient’smajorproblemistheimpairedskinintegrityasdemonstrated bythepresence ofa .xi ba
. pressure ulcer.Thenurseisabletotreatthecauseofalteredcirculationandpressurebyfrequently
x i ba . x i
. repositioningthepatient.Although left-sidedweaknessisaproblemforthepatient,
x i . x i ba ba ba ba
thenursecannot treattheweakness.The“riskfor”diagnosisisnot appropriateforthispatient,
.xi .xi ba ba
whoalreadyhas impairedtissueintegrity.The patient doeshave ineffectivetissue perfusion,
.xi .xi .xi ba
but theimpaired skin integritydiagnosisindicatesmoreclearlywhatthehealthproblemis.
.xi ba . x i
DIF: CognitiveLevel:Apply(application) ba REF: 7
TOP: NursingProcess: Diagnosis .xi MSC: . x NCLEX:PhysiologicalIntegrity
i
, 6. Apatientwithabacterialinfectionhas a nursingdiagnosisof deficient fluidvolume relatedto
ba ba .xi ba ba ba ba ba ba
.xi excessivediaphoresis.Which outcome would the nurse recognize asappropriate forthispatient? .xi ba
a. Patienthasa balancedintakeand output. ba ba .xi
b. Patient’sbeddingischanged when itbecomes damp. ba ba ba .x i
c. Patientunderstandstheneedforincreased fluid intake. ba ba
d. Patient’sskin remainscooland drythroughout hospitalization.
ba ba ba .xi
ANS: A . x i
Thisstatementgivesmeasurabledatashowingresolutionoftheproblemofdeficientfluidvolume
ba
thatwasidentifiedinthenursing diagnosisstatement.Theotherstatementswouldnot indicate that
.xi ba ba ba ba .xi
theproblemofdeficientfluidvolumewasresolved.
.xi
DIF: CognitiveLevel:Apply(application) ba REF: 7
TOP: NursingProcess:Planning ba .xi MSC: . NCLEX:PhysiologicalIntegrity
x i
7. Anurseasks thepatientifpainwasrelievedafterreceivingmedication.Whatisthe purposeofthe
ba ba ba ba ba .xi
.xi evaluationphaseofthenursing process? ba
a. Todetermineifinterventionshavebeeneffectiveinmeetingpatientoutcomes ba .xi
b. Todocumentthe nursingcareplan in theprogress notesofthemedicalrecord ba ba ba .xi
c. Todecidewhetherthepatient’shealthproblemshavebeencompletelyresolved .xi
d. Toestablishifthepatientagreesthatthenursingcareprovidedwas satisfactory ba ba . x i . x i
ANS: A . x i
Evaluation consists of determining whether the desired patient outcomes have been met and
.xi .xi .xi .xi .xi .xi .xi .xi .xi .xi .xi .xi
whether the nursing interventions were appropriate. The other responses do not describe the
.xi .xi .xi .xi .xi .xi .xi .xi .xi .xi .xi .xi .xi
evaluationphase.
.xi
DIF: CognitiveLevel: Understand(comprehension) REF: 5 .xi
TOP: Nursing Process:Evaluation MSC: NCLEX:SafeandEffectiveCareEnvironment
ba . x i ba
8. Thenurseinterviews apatientwhilecompletingthehealthhistoryandphysicalexamination.What ba ba ba ba .xi
isthepurposeoftheassessmentphaseofthenursingprocess?
.xi
a. Toteachinterventionsthatrelievehealthproblems ba
b. Tousepatientdatatoevaluatepatientcareoutcomes ba
c. Toobtaindatawithwhichtodiagnosepatientproblems ba
d. Tohelpthepatientidentifyrealisticoutcomesforhealthproblems
ANS: C . x i
Duringtheassessmentphase,thenursegathersinformationabout thepatienttodiagnosepatient
ba ba .xi
problems.Theotherresponsesareexamplesoftheplanning,intervention,and evaluation phasesof
.xi .xi .xi .xi ba ba
thenursingprocess.
.xi
DIF: CognitiveLevel: Understand(comprehension) REF: 5 .xi
TOP: NursingProcess:Assessment MSC: NCLEX:SafeandEffectiveCareEnvironment
ba . x i ba ba
9. Which nursingdiagnosisstatementiswrittencorrectly?
ba .xi ba
a. Altered tissue perfusionrelatedtoheart failure ba ba .xi ba
b. Risk forimpairedtissueintegrityrelated tosacralredness
b .xi ba .xi
c. Ineffectivecopingrelatedtoresponsetobiopsytestresults
d. Altered urinaryeliminationrelatedtourinarytractinfection
ba .xi
.xi .xi .xi .xi .xi
Medical-SurgicalNursing,10thEdition a
b a
b
MULTIPLECHOICE
1. Thenursecompletesanadmissiondatabaseandexplainsthattheplanofcareanddischargegoals . x i
. willbedevelopedwiththepatient’sinput.Thepatientstates,“Howisthisdifferentfromwhatthe
x i ba ba .xi
doctordoes?”Whichresponsewouldbemostappropriateforthenursetomake?
.xi .xi .xi .xi
a. “Theroleofthenurseistoadministermedicationsand othertreatmentsprescribedby ba ba .xi
yourdoctor.” .xi
b. “Thenurse’sjobistohelpthedoctorbycollectinginformationand .xi ba
communicatinganyproblemsthatoccur.”
.xi
c. “Nursesperformmanyofthesameproceduresasthedoctor, but nurses arewiththe ba .xi ba ba ba .xi
patientsforalongertimethanthedoctor.”
.xi
d. “Inadditiontocaringforyouwhile youaresick,thenurseswillassist youto ba .xi ba ba
developanindividualizedplantomaintainyourhealth.”
.xi
ANS: D . x i
ThisresponseisconsistentwiththeAmericanNursesAssociation(ANA)definitionofnursing, .xi .xi .xi .xi
which describestheroleofnursesinpromotinghealth.Theotherresponsesdescribe someofthe
.xi ba .xi ba
dependent andcollaborative functionsofthenursing role butdonotaccuratelydescribethenurse’s
.xi ba .xi
. roleinthehealthcaresystem.
x i
DIF: CognitiveLevel:Understand(comprehension) ba ba REF: 3
TOP: NursingProcess: Implementation MSC: .xi . x i NCLEX:SafeandEffectiveCareEnvironment ba
2. Thenursedescribestoastudentnursehowtouseevidence-basedpracticeguidelineswhen
. x i caringforpatients.Whichstatement,ifmadebythenurse,wouldbethemost accurate? .xi .xi .xi .xi .xi .xi .xi
a. “Inferencesfrom clinicalresearchstudiesareusedasa guide.” ba .xi ba .xi ba ba
b. “Patientcareisbasedonclinicaljudgment,experience, and traditions.” .xi ba
c. “Data are evaluatedtoshowthatthepatientoutcomesareconsistentlymet.”
ba . x i ba
d. “Recommendationsarebasedonresearch,clinicalexpertise,andpatient ba ba ba ba ba
preferences.”
.xi
ANS: D . x i
Evidence-basedpractice(EBP)istheuseofthebestresearch-basedevidencecombinedwith .xi
.clinicianexpertise.Clinicaljudgmentbased onthenurse’sclinicalexperienceispartofEBP,but
x i ba ba ba ba .xi
clinical decisionmakingshouldalsoincorporate currentresearchandresearch-based guidelines.
.xi ba ba ba . x i
. Evaluationof patientoutcomesisimportant,but interventionsshould bebasedonresearchfrom
x i ba ba ba ba .xi
randomized controlstudieswithalargenumberofsubjects.
.xi ba
DIF: CognitiveLevel:Remember(knowledge) ba REF: 15
TOP: NursingProcess:Planning MSC: ba .xi . x i NCLEX:SafeandEffectiveCareEnvironment ba
3. Thenurseteachesastudentnurseabouthowtoapplythenursingprocesswhenproviding ba ba
patientcare. Whichstatement, ifmadebythestudentnurse,indicatesthatteachingwas
.xi .xi .xi
successful?
.xi
a. “Thenursingprocessisascientific-basedmethodofdiagnosingthepatient’s ba ba ba
healthcareproblems.” .xi
b. “Thenursing processisaproblem-solving toolused toidentifyandtreat patients’
ba ba .xi ba .xi ba ba
, healthcareneeds.” ba
c. “Thenursingprocessisusedprimarilytoexplainnursinginterventionstoother
ba ba ba ba ba
healthcareprofessionals.”
. x i
d. “Thenursingprocessisbasedonnursingtheorythatincorporatesthe ba ba ba ba ba
biopsychosocialnatureofhumans.”
.xi
ANS: B . x i
Thenursingprocessisaproblem-solvingapproachtotheidentificationandtreatmentofpatients’ ba . x i
. problems.Diagnosisisonlyonephaseofthenursingprocess.Theprimaryuseofthe
x i .xi ba
nursingprocess isinpatientcare,
.xi .xi
nottoestablishnursingtheoryorexplainnursing interventionstootherhealthcare
.xi ba
. professionals.
x i
DIF: CognitiveLevel:Understand(comprehension) ba REF: 5
TOP: NursingProcess: Implementation MSC: .xi . x i NCLEX:SafeandEffectiveCareEnvironment ba
4. Apatienthasbeenadmittedtothehospitalforsurgeryandtellsthenurse,“Idonotfeel ba ba . x i . x i
. x i comfortableleavingmychildrenwithmyparents.”Whichactionshouldthenursetakenext
ba ba ba ba ba ba
?
a. Reassurethepatient that thesefeelingsarecommonforparents. ba .xi
b. Havethepatientcallthe childrentoensurethat theyaredoingwell. .xi ba
c. Gathermoredataabout thepatient’sfeelingsaboutthechild-carearrangements. ba ba
d. Callthepatient’sparentstodeterminewhetheradequatechildcareisbeing
ba ba
provided.
.xi
ANS: C . x i
Becauseacompleteassessmentisnecessaryinordertoidentifyaproblemandchoosean ba ba . x i
. appropriateintervention,thenurse’sfirstactionshould be toobtainmoreinformation.Theother
x i .xi .xi .xi .xi ba .xi
actionsmaybeappropriate,butmoreassessmentisneeded beforethebestinterventioncanbe
.xi ba ba .xi
chosen.
.xi
DIF: CognitiveLevel:Apply(application) REF: 6
OBJ: SpecialQuestions:Prioritization .xi .xi TOP: NursingProcess:Assessment
. xi ba
MSC:.xi NCLEX:PsychosocialIntegrity . x i .xi .xi
5. Apatient whoisparalyzed ontheleftsideofthebodyafterastrokedevelops a pressure ulceronthe
ba ba ba .xi ba ba ba .xi
.xi lefthip.Which nursing diagnosisismostappropriate?
.xi ba .xi .xi
a. Impairedphysicalmobilityrelatedtoleft-sidedparalysis
b. Risk forimpaired tissueintegrityrelatedtoleft-sidedweakness
ba . x i
c. Impairedskinintegrityrelated toaltered circulationandpressure ba ba .xi
d. Ineffectivetissueperfusionrelatedtoinabilitytomoveindependently
ANS: C . x i
Thepatient’smajorproblemistheimpairedskinintegrityasdemonstrated bythepresence ofa .xi ba
. pressure ulcer.Thenurseisabletotreatthecauseofalteredcirculationandpressurebyfrequently
x i ba . x i
. repositioningthepatient.Although left-sidedweaknessisaproblemforthepatient,
x i . x i ba ba ba ba
thenursecannot treattheweakness.The“riskfor”diagnosisisnot appropriateforthispatient,
.xi .xi ba ba
whoalreadyhas impairedtissueintegrity.The patient doeshave ineffectivetissue perfusion,
.xi .xi .xi ba
but theimpaired skin integritydiagnosisindicatesmoreclearlywhatthehealthproblemis.
.xi ba . x i
DIF: CognitiveLevel:Apply(application) ba REF: 7
TOP: NursingProcess: Diagnosis .xi MSC: . x NCLEX:PhysiologicalIntegrity
i
, 6. Apatientwithabacterialinfectionhas a nursingdiagnosisof deficient fluidvolume relatedto
ba ba .xi ba ba ba ba ba ba
.xi excessivediaphoresis.Which outcome would the nurse recognize asappropriate forthispatient? .xi ba
a. Patienthasa balancedintakeand output. ba ba .xi
b. Patient’sbeddingischanged when itbecomes damp. ba ba ba .x i
c. Patientunderstandstheneedforincreased fluid intake. ba ba
d. Patient’sskin remainscooland drythroughout hospitalization.
ba ba ba .xi
ANS: A . x i
Thisstatementgivesmeasurabledatashowingresolutionoftheproblemofdeficientfluidvolume
ba
thatwasidentifiedinthenursing diagnosisstatement.Theotherstatementswouldnot indicate that
.xi ba ba ba ba .xi
theproblemofdeficientfluidvolumewasresolved.
.xi
DIF: CognitiveLevel:Apply(application) ba REF: 7
TOP: NursingProcess:Planning ba .xi MSC: . NCLEX:PhysiologicalIntegrity
x i
7. Anurseasks thepatientifpainwasrelievedafterreceivingmedication.Whatisthe purposeofthe
ba ba ba ba ba .xi
.xi evaluationphaseofthenursing process? ba
a. Todetermineifinterventionshavebeeneffectiveinmeetingpatientoutcomes ba .xi
b. Todocumentthe nursingcareplan in theprogress notesofthemedicalrecord ba ba ba .xi
c. Todecidewhetherthepatient’shealthproblemshavebeencompletelyresolved .xi
d. Toestablishifthepatientagreesthatthenursingcareprovidedwas satisfactory ba ba . x i . x i
ANS: A . x i
Evaluation consists of determining whether the desired patient outcomes have been met and
.xi .xi .xi .xi .xi .xi .xi .xi .xi .xi .xi .xi
whether the nursing interventions were appropriate. The other responses do not describe the
.xi .xi .xi .xi .xi .xi .xi .xi .xi .xi .xi .xi .xi
evaluationphase.
.xi
DIF: CognitiveLevel: Understand(comprehension) REF: 5 .xi
TOP: Nursing Process:Evaluation MSC: NCLEX:SafeandEffectiveCareEnvironment
ba . x i ba
8. Thenurseinterviews apatientwhilecompletingthehealthhistoryandphysicalexamination.What ba ba ba ba .xi
isthepurposeoftheassessmentphaseofthenursingprocess?
.xi
a. Toteachinterventionsthatrelievehealthproblems ba
b. Tousepatientdatatoevaluatepatientcareoutcomes ba
c. Toobtaindatawithwhichtodiagnosepatientproblems ba
d. Tohelpthepatientidentifyrealisticoutcomesforhealthproblems
ANS: C . x i
Duringtheassessmentphase,thenursegathersinformationabout thepatienttodiagnosepatient
ba ba .xi
problems.Theotherresponsesareexamplesoftheplanning,intervention,and evaluation phasesof
.xi .xi .xi .xi ba ba
thenursingprocess.
.xi
DIF: CognitiveLevel: Understand(comprehension) REF: 5 .xi
TOP: NursingProcess:Assessment MSC: NCLEX:SafeandEffectiveCareEnvironment
ba . x i ba ba
9. Which nursingdiagnosisstatementiswrittencorrectly?
ba .xi ba
a. Altered tissue perfusionrelatedtoheart failure ba ba .xi ba
b. Risk forimpairedtissueintegrityrelated tosacralredness
b .xi ba .xi
c. Ineffectivecopingrelatedtoresponsetobiopsytestresults
d. Altered urinaryeliminationrelatedtourinarytractinfection
ba .xi
