LEMONE AND BURKE'S MEDICAL-
SURGICAL NURSING
CLINICAL REASONING IN PATIENT CARE
7TH EDITION
AUTHOR(S)GERENE BAULDOFF RN,
PHD, FAAN; PAULA GUBRUD;
MARGARET CARNO
TEST BANK
1) MCQ
Clinical Scenario:
A nurse begins the shift caring for a 69-year-old patient
admitted with weakness and poor appetite. The patient says,
,“Something just feels off today,” but cannot clearly describe
the problem. The nurse checks the patient’s vital signs, reviews
the latest labs, and assesses skin color, orientation, and pain
level before deciding what to do next.
Question Stem:
Which step of the nursing process is the nurse primarily using?
Answer Options:
A. Assessment
B. Diagnosis
C. Implementation
D. Evaluation
Correct Answer:
A. Assessment
Detailed Rationale:
Assessment is the systematic collection of data and cues before
making judgments. The nurse is gathering subjective and
objective information to understand the patient’s condition.
This is the foundation of clinical reasoning because accurate
assessment guides all later steps.
Incorrect Option Analysis:
B. Diagnosis — Diagnosis comes after cue analysis, when
the nurse interprets data and identifies the patient
problem.
C. Implementation — Implementation is the action phase,
such as giving interventions or teaching.
, D. Evaluation — Evaluation occurs after interventions to
determine whether goals were met.
Nursing Process Linkage: Assessment
Clinical Judgment Competencies (NCJMM): Recognize Cues
Clinical Reasoning Focus: Cue Recognition
Difficulty Level: Easy
Bloom’s Cognitive Level: Understand
NCLEX Client Needs Category: Reduction of Risk Potential
Key Learning Objective: Identify assessment as the first step in
safe nursing decision-making.
2) MCQ
Clinical Scenario:
A postoperative patient says, “I do not understand why I need
to keep using this breathing device.” The nurse notes shallow
respirations, guarding of the incision, and reluctance to cough.
Question Stem:
Which nursing diagnosis best matches the cues?
Answer Options:
A. Acute pain related to tissue trauma as evidenced by guarding
and report of pain
B. Risk for infection related to surgery as evidenced by shallow
respirations
C. Ineffective coping related to hospitalization as evidenced by
refusal to talk
, D. Deficient fluid volume related to poor appetite as evidenced
by confusion
Correct Answer:
A. Acute pain related to tissue trauma as evidenced by
guarding and report of pain
Detailed Rationale:
The patient’s cues point to acute pain: guarding, shallow
respirations, and reluctance to cough are common pain-related
behaviors after surgery. A clear nursing diagnosis links the
problem, cause, and supporting evidence.
Incorrect Option Analysis:
B. Risk for infection — This is a valid postoperative risk,
but the supporting cues given do not indicate infection.
C. Ineffective coping — The patient’s statement shows
lack of understanding, not necessarily maladaptive coping.
D. Deficient fluid volume — No cues such as hypotension,
tachycardia, dry mucosa, or decreased urine output were
provided.
Nursing Process Linkage: Diagnosis
Clinical Judgment Competencies (NCJMM): Analyze Cues;
Prioritize Hypotheses
Clinical Reasoning Focus: Data Interpretation
Difficulty Level: Moderate
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
SURGICAL NURSING
CLINICAL REASONING IN PATIENT CARE
7TH EDITION
AUTHOR(S)GERENE BAULDOFF RN,
PHD, FAAN; PAULA GUBRUD;
MARGARET CARNO
TEST BANK
1) MCQ
Clinical Scenario:
A nurse begins the shift caring for a 69-year-old patient
admitted with weakness and poor appetite. The patient says,
,“Something just feels off today,” but cannot clearly describe
the problem. The nurse checks the patient’s vital signs, reviews
the latest labs, and assesses skin color, orientation, and pain
level before deciding what to do next.
Question Stem:
Which step of the nursing process is the nurse primarily using?
Answer Options:
A. Assessment
B. Diagnosis
C. Implementation
D. Evaluation
Correct Answer:
A. Assessment
Detailed Rationale:
Assessment is the systematic collection of data and cues before
making judgments. The nurse is gathering subjective and
objective information to understand the patient’s condition.
This is the foundation of clinical reasoning because accurate
assessment guides all later steps.
Incorrect Option Analysis:
B. Diagnosis — Diagnosis comes after cue analysis, when
the nurse interprets data and identifies the patient
problem.
C. Implementation — Implementation is the action phase,
such as giving interventions or teaching.
, D. Evaluation — Evaluation occurs after interventions to
determine whether goals were met.
Nursing Process Linkage: Assessment
Clinical Judgment Competencies (NCJMM): Recognize Cues
Clinical Reasoning Focus: Cue Recognition
Difficulty Level: Easy
Bloom’s Cognitive Level: Understand
NCLEX Client Needs Category: Reduction of Risk Potential
Key Learning Objective: Identify assessment as the first step in
safe nursing decision-making.
2) MCQ
Clinical Scenario:
A postoperative patient says, “I do not understand why I need
to keep using this breathing device.” The nurse notes shallow
respirations, guarding of the incision, and reluctance to cough.
Question Stem:
Which nursing diagnosis best matches the cues?
Answer Options:
A. Acute pain related to tissue trauma as evidenced by guarding
and report of pain
B. Risk for infection related to surgery as evidenced by shallow
respirations
C. Ineffective coping related to hospitalization as evidenced by
refusal to talk
, D. Deficient fluid volume related to poor appetite as evidenced
by confusion
Correct Answer:
A. Acute pain related to tissue trauma as evidenced by
guarding and report of pain
Detailed Rationale:
The patient’s cues point to acute pain: guarding, shallow
respirations, and reluctance to cough are common pain-related
behaviors after surgery. A clear nursing diagnosis links the
problem, cause, and supporting evidence.
Incorrect Option Analysis:
B. Risk for infection — This is a valid postoperative risk,
but the supporting cues given do not indicate infection.
C. Ineffective coping — The patient’s statement shows
lack of understanding, not necessarily maladaptive coping.
D. Deficient fluid volume — No cues such as hypotension,
tachycardia, dry mucosa, or decreased urine output were
provided.
Nursing Process Linkage: Diagnosis
Clinical Judgment Competencies (NCJMM): Analyze Cues;
Prioritize Hypotheses
Clinical Reasoning Focus: Data Interpretation
Difficulty Level: Moderate
Bloom’s Cognitive Level: Analyze
NCLEX Client Needs Category: Physiological Adaptation
