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Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada
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Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
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MULTIPLE CHOICE YF
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1. When caring for clients using evidence-informed practice, which of the following does
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a. Clinical judgement based on experience L
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b. Evidence from a clinical research study Y.F,TL Y.F,TL YF L
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c. The best available evidence to guide clinical expertise L
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d. Evaluation of data showing that the client outcomes are met Y.F,TL Y.F,T L Y.F,T L Y.F,TL Y.F,T L L
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ANS: Y . F , T L C
Evidence-informed nursing practice is a continuous interactive process involving the Y.F, T L Y.F,T L Y. F,T L Y. F,T L Y.F ,T L Y.F,T L Y.F, T L Y.F, T L Y.F, TL
explicit, conscientious, and judicious consideration of the best available evidence to provide
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care. Four primary elements are: (a) clinical state, setting, and circumstances; (b) client
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preferences and actions; (c) best research evidence; and (d) health care resources. Clinical
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judgement based on the nurse’s clinical experience is part of EIP, but clinical decision
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making also should incorporate current research and research-based guidelines. Evidence
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from one clinical research study does not provide an adequate substantiation for
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interventions. Evaluation of client outcomes is important, but interventions should be
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based on research from randomized control studies with a large number of subjects.
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2. Which of the following best e xp l a i n s t h e nu r s e s ’ pr imary use of the nursing process
when
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providing care to clients? Y.F,T L Y.F,T L Y.F, T L
a. To explain nursing interventions to other health care professionals Y.F,T L Y.F,T L Y.F,T L L
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b. As a problem-solving tool to identify and treat clients’ health care needs Y.F,T L Y.F,T L Y.F,T L Y.F,TL Y.F,T L Y.F,T L Y.F,TL Y.F,TL Y.F,T L L
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c. As a scientific-based process of diagnosing the client’s health care problems YF L
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d. To establish nursing theory that incorporates the biopsychosocial nature of humans Y.F,T L L
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ANS: Y . F , T L B
The nursing process is an assertive problem-solving approach to the identification and
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treatment of clients’ problems. Diagnosis is only one phase of the nursing process. The
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primary use of the nursing process is in client care, not to establish nursing theory or
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explain nursing interventions to other health care professionals.
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3. The nurse is caring for a critically ill client in the intensive care unit and plans an every 2-
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hour turning schedule to prevent skin breakdown. Which type of nursing function is
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demonstrated with this turning schedule?
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a. Dependent
b. Cooperative
c. Independent
d. Collaborative
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, Medical-Surgical Nursing in Canada 4th Edition Lewi Test Y.F, T L Y.F, T L Y. F,T L Y.F, T L Y. F,T L Y. F,T L Y.F, T L
Bank
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When implementing collaborative nursing actions, the nurse is responsible primarily for
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monitoring for complications of acute illness or providing care to prevent or treat
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complications. Independent nursing actions are focused on health promotion, illness
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prevention, and client advocacy. A dependent action would require a physician order to
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implement. Cooperative nursing functions are not described as one of the formal nursing
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functions.
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4. The nurse is caring for a client who has been admitted to the hospital for surgery and tells
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the nurse, “I do not feel right about leaving my children with my neighbour.” Which
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action should the nurse take next?
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a. Reassure the client that these feelings are common for parents. YF L
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b. Have the client call the children to ensure that they are doing well. L
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c. Call the neighbour to determine whether adequate childcare is being provided.
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d. Gather more data about the client’s feelings about the childcare arrangements. YF L
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ANS: Y . F , T L D
Since a complete assessment is necessary in order to identify a problem and choose an
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appropriate intervention, the nurse’s first action should be to obtain more information.
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The other actions may be appropriate, but more assessment is needed before the best
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intervention can be chosen.
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5. The nurse is caring for a client who has left-sided paralysis as the result of a stroke and
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assesses a pressure injury o n t he clie nt ’s left h ip . W hich of the following is the most
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appropriate nursing diagnosis fUo r t S h is cNl i e nTt ? O Y .F , T L Y . F , T L Y . F , T L Y .F , T L Y . F , T L
a. Impaired physical mobility related to decrease in muscle control (left- Y.F,T L L
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b. Risk for impaired tissue integrity as evidenced by insufficient knowledge L
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about protecting tissue integrity
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c. Impaired skin integrity related to pressure over bony prominence (impaired L
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circulation) Y.F,T L
d. Ineffective tissue perfusion related to sedentary lifestyle L
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ANS: Y . F , T L C
The client’s major problem is the impaired skin integrity as demonstrated by the presence of
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a pressure injury. The nurse is able to treat the cause of altered circulation and pressure
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by frequently repositioning the client. Although left-sided weakness is a problem for the
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client, the nurse cannot treat the weakness. The “risk for” diagnosis is not appropriate
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for this client, who already has impaired tissue integrity. The client does have ineffective
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tissue perfusion, but the impaired skin integrity diagnosis indicates more clearly what the
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health problem is.
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6. The nurse caring for a client with an infection has a nursing diagnosis of deficient
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fluid volume related to excessive diaphoresis. Which of the following is an
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appropriate client outcome?
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a. Client has a balanced intake and output. Y.F,T L L
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b. Client’s bedding is changed when it becomes damp. Y.F,TL Y.F,T L Y.F,T L Y.F,T L Y.F,T L Y.F,TL Y.F,T L
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, Medical-Surgical Nursing in Canada 4th Edition Lewi Test Y.F, T L Y.F, TL Y. F,T L Y.F, T L Y. F,T L Y. F,T L L
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c. Client understands the need for increased fluid intake. L
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d. Client’s skin remains cool and dry throughout hospitalization. Y.F,T L Y.F,T L Y.F,T L Y.F,T L Y.F,T L Y.F,TL Y.F,T L
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This statement gives measurable data showing resolution of the problem of deficient fluid
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volume that was identified in the nursing diagnosis statement. The other statements would not
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indicate that the problem of deficient fluid volume was resolved.
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7. Which of the following represents a nursing activity that is carried out during the
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evaluation phase of the nursing process?
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a. Determining if interventions have been effective in meeting client outcomes L
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b. Documenting the nursing care plan in the progress notes in the medical record Y.F,T L Y.F,T L Y.F ,T L L
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c. Deciding whether the client’s health problems have been completely resolved YF
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d. Asking the client to evaluate whether the nursing care provided was satisfactory Y.F,T L Y.F,T L Y.F,T L L
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ANS: Y . F , T L A
Evaluation consists of determining whether the desired client outcomes have been met Y.F, T L L
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and whether the nursing interventions were appropriate. The other responses do not
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describe the evaluation phase.
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8. Which of the following would the nurse perform during the assessment phase of the
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nursing process?
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a. Obtains data with which to diagnose client problems L
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b. Uses client data to develoN pUpR
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c. Teaches interventions to relieve client health problems L
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d. Assists the client to identify realistic outcomes to health problems YF
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ANS: Y . F , T L A
During the assessment phase, the nurse gathers information about the client. The other
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responses are examples of the intervention, diagnosis, and planning phases of the nursing
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process.
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9. Which of the following is an example of a correctly written nursing diagnosis statement?
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a. Altered tissue perfusion related to heart failure Y.F,TL Y.F,TL Y.F,T L Y.F,T L Y.F,T L Y.F,T L
b. Risk for impaired tissue integrity related to sacral redness
Y.F,T L Y.F,T L Y.F,T L L
Y.F,T L
Y.F,T Y.F,T L L
Y.F,T Y. F, T L
c. Ineffective coping related to insufficient sense of control. Y.F,T L Y.F,T L Y.F,TL Y.F,T L Y.F,T L Y.F,TL Y.F,T L
d. Altered urinary elimination related to urinary tract infection Y.F,TL L
Y.F,T Y.F,T L Y.F,T L Y.F,T L Y.F,T L Y.F,T L
ANS: Y . F , T L C
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes
L
Y.F,T L
Y.F,T YF L
.,T YF L
. ,T L
Y.F,T YF L
.,T L
Y.F,T L
Y.F,T L
Y.F,T L
Y.F,T YF L
. ,T YF L
.,T
a client’s response to a health problem that can be treated by nursing. The use of a
Y.F,T L L
Y.F, T Y.F, T L Y. F,T L Y.F,T L Y.F,T L Y. F,T L Y .F,T L Y.F,T L Y.F, T L L
Y.F, T L
Y.F,T Y.F ,T L Y.F,T L L
Y.F, T L
Y.F, T Y.F ,T L
medical diagnosis (as in the responses beginning “Altered tissue perfusion” and “Altered
Y.F,T L Y.F, T L Y. F,T L Y. F,T L Y.F, T L Y .F,T L Y.F,T L Y.F,T L Y.F, T L Y. F,T L Y.F, T L Y.F, T L
urinary elimination”) is not appropriate. The response beginning “Risk for impaired
Y.F,T L Y.F, T L Y. F,T L Y.F ,T L L
Y.F,T Y.F,T L Y.F, T L Y.F, T L Y. F,T L Y.F, TL Y.F, T L
tissue integrity” uses the defining characteristics as the etiology.
Y.F,T L Y.F,T L Y.F, T L Y. F,T L Y.F ,T L Y. F,T L Y.F ,TL Y.F, T L L
Y.F, T
DIF: Cognitive Level: Comprehension Y.F,T L Y.F,T L TOP: Y . F , T L Nursing Process: Diagnosis Y.F,T L Y.F,T L
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, Medical-Surgical Nursing in Canada 4th Edition Lewi Test Y.F, T L Y.F, T L Y. F,T L Y.F, T L Y. F,T L Y. F,T L L
Y.F, T
Bank
Y.F,T L
10. Which of the following includes the components required for a complete nursing
Y.F,T L YF
.,T L Y.F,T L L
Y.F,T Y.F,T L YF
. ,TL Y.F,TL Y.F,T L L
Y.F,T L
Y.F,T L
Y.F,T
YF L
. ,T diagnosis statement? Y.F, T L
a. A problem and the suggested client goals or outcomes
YF
.,TL L
Y.F,T L
Y.F,T Y.F,T L L
Y.F,T Y.F,T L L
Y.F,T Y.F,T L
b. A problem, its cause, and objective data that support the problem
YF
.,TL Y.F,T L L
Y.F,T Y.F,T L Y. F, T L L
Y.F,T L
Y.F,T Y.F,T L Y.F,T L Y.F,T L
c. A problem with all its possible causes and the planned interventions
Y.F,T L Y.F,T L Y.F,T L Y.F,T L L
Y.F,T Y.F,T L L
Y.F,T Y.F,T L Y.F,T L Y.F,TL
d. A problem with its etiology and the signs and symptoms of the problem
Y.F,T L Y.F,T L Y.F,T L Y.F,T L Y.F,T L L
Y.F,T L
Y.F,T L
Y.F,T L
Y.F,T Y.F,T L L
Y.F,T Y.F,T L
ANS: Y . F , T L D
The PES format is used when writing nursing diagnoses. The subjective, as well as objective,
YF L
.,T L
Y.F,T L
Y.F,T Y.F,T L Y.F,T L Y.F,T L L
Y.F,T Y.F,T L L
Y.F,T L
Y.F,T Y.F,TL L
Y.F,T L
Y.F,T L
Y.F,T
data should be included in the defining characteristics. Interventions and outcomes are not
Y.F,T L L
Y.F,T Y.F, T L Y.F, T L Y. F,T L Y.F, T L Y.F, T L L
Y.F, T Y.F, T L Y. F,T L Y. F,T L Y. F,T L Y.F, T L
included in the nursing diagnosis statement.
Y.F,T L Y.F, TL Y. F,T L Y.F, T L L
Y.F, T Y.F, T L
DIF: Cognitive Level: Knowledge L
Y.F,T Y.F,TL TOP: Y . F , T L Nursing Process: Diagnosis L
Y.F,T L
Y.F,T
11. Which of the following refers to a situation that results in unintended harm to the client and
Y.F,T L YF
.,T L Y.F,T L Y.F,T L Y.F,T L L
Y.F,T YF
. ,TL Y.F,T L YF L
. ,T Y.F,T L Y.F,TL L
Y.F,T Y.F,T L Y.F,TL YF L
.,T L
Y.F,T
is related to the care or services provided rather than the client’s medical condition?
YF L
. ,T Y. F,T L Y.F,TL Y.F,T L Y.F, T L Y.F, T L Y.F,T L L
Y.F, T Y. F,T L Y.F,T L L
Y.F, T Y. F,T L Y. F,T L Y.F, T L
a. Negligence
b. Adverse event YF
.,T L
c. Incident report YFL
.,T
d. Nonmaleficence
ANS: Y . F , T L B
An adverse event is an event that results in unintended harm to the client and is related to
L
Y.F,T L
Y.F,T Y.F,TL L
Y.F,T L
Y. F, T Y.F,TL Y.F,T L Y.F,T L L
Y.F,T Y.F,T L Y.F,TL Y.F,T L L
Y.F,T L
Y.F,T L
Y.F,T L
Y.F,T L
Y.F,T
the
Y.F,T L
care or services provided to the client rather than to the client’s underlying medical
YF L
.,T Y.F,T L Y.F,T L Y .F, T L Y.F,TL Y.F,T L L
Y.F,T YF L
. ,T L
Y.F,T L
Y.F,T Y.F,T L Y.F,T L Y.F ,T L
condition.
Y.F,T L
DIF: Cognitive Level: Knowledge L
Y.F,T Y.F,TL TOP: Y . F , T L Nursing Process: Evaluation L
Y.F,T L
Y.F,T
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12. When using the Five Steps of the evidence-informed practice (EIP) Process, which of the
YF L
. ,T Y.F,T L Y.F,T L L
Y.F,T Y.F,TL L
Y.F,T Y.F,TL L
Y.F,T Y.F,T L Y.F,T L L
Y.F,T L
Y.F,T L
Y.F,T
flowing elements is the final step when constructing a clinical question? L
Y.F,T Y.F,T L Y.F,T L Y.F,T L L
Y.F,T Y.F,T L Y.F,T L Y.F,T L Y.F,T L Y.F,T L
a. Comparison of interest Y.F,T L Y.F,T L
b. Population of interest Y.F, T L Y.F, T L
c. Outcome of interest L
Y.F,T Y.F,T L
d. Timeframe of interest Y.F,T L Y.F,T L
ANS: Y . F , T L D
The order of the nurse’s statements follows the PICOT format with the final step being the
YF L
.,T YF
. ,T L Y.F,T L YF L
.,T L
Y.F,T Y.F,T L L
Y.F,T Y.F,TL YF L
.,T Y.F,TL YF
.,T L L
Y.F,T L
Y.F,T L
Y.F,T Y.F,T L
“T”, or timeframe of interest.
Y.F,T L Y.F,T L Y.F,T L Y. F,T L Y.F, T L
DIF: Cognitive Level: Application L
Y.F,T Y.F,TL TOP: Y . F , T L Nursing Process: Implementation L
Y.F,T L
Y.F,T
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