TEST BANK FOR Lewis's Medical-Surgical Nursing in Canada 5th edition by Jane Tyerman ISBN:978-0323791571 COMPLETE GUIDE 100% VERIFIED A+ GRADE ASSURED!!!!NEW LATEST UPDATE!!!!!

Medical-


Chapter 01: Introduction to Medical-
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Surgical Nursing Practice in Canada Lewis: Medical-
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Surgical Nursing in Canada, 5th Canadian Edition
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MULTIPLE CHOICE fh




1. When caring for clients using evidence-
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informed practice, which of the following does the nurse use?
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a. Clinical judgement based on experience
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b. Evidence from a clinical research study fh fh fh fh fh



c. The best available evidence to guide clinical expertise
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d. Evaluation of data showing that the client outcomes are met fh fh fh fh fh fh fh fh fh




ANS: C
Evidence-
informed nursing practice is a continuous interactive process involving the explicit, conscient i
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ous, and judicious consideration of the best available evidence to provide care. Four primary el
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ements are: (a) clinical state, setting, and circumstances; (b) client preferences and actions;
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(c) best research evidence; and (d) health care resources. Clinical judgement based on the nurs e‘
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s clinical experience is part of EIP, but clinical decision making also should incorporate cur rent
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research and research-
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based guidelines. Evidence from one clinical research study does not provide an adequate sub st
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antiation for interventions. Evaluation of client outcomes is important, but interventions sho uld
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be based on research from randomized control studies with a large number of subjects.
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DIF: f h f h Cognitive Level: Comprehension fh fh f h f h f h TOP: f h f h Nursing Process: Planning fh fh




2. Which of the following best N
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explRa insItheGnu Br s .
drfh imary use of the nursing process when
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providing care to clients USNT O fh fh fh h
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?
a. To explain nursing interventions to other health care professionals
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b. As a problem-solving tool to identify and treat clients‘ health care needs
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c. As a scientific-based process of diagnosing the client‘s health care problems
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d. To establish nursing theory that incorporates the biopsychosocial nature of humans
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ANS: B
The nursing process is an assertive problem-
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solving approach to the identification and treatment of clients‘ problems. Diagnosis is only on e
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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 explain n ursin
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g interventions to other health care professionals.
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DIF: Cognitive Level: Comprehension fh fh TOP: Nursing Process: Implementation fh fh




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 demonst r
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ated with this turning schedule?
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a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: D




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When implementing collaborative nursing actions, the nurse is responsible primarily for mon it
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oring for complications of acute illness or providing care to prevent or treat complications. Inde
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pendent nursing actions are focused on health promotion, illness prevention, and client a dvoca
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cy. A dependent action would require a physician order to implement. Cooperative nur sing fun
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ctions are not described as one of the formal nursing functions.
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DIF: Cognitive Level: Application fh fh TOP: Nursing Process: Implementation fh fh




4. The nurse is caring for a client who has been admitted to the hospital for surgery and tells th e
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nurse, ―I do not feel right about leaving my children with my neighbour.‖ Which action sh oul
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d the nurse take next?
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a. Reassure the client that these feelings are common for parents. fh fh fh fh fh fh fh fh fh



b. Have the client call the children to ensure that they are doing well.
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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.
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ANS: D
Since a complete assessment is necessary in order to identify a problem and choose an appro pri
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ate intervention, the nurse‘s first action should be to obtain more information. The other ac tion
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s may be appropriate, but more assessment is needed before the best intervention can be c hosen
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.

DIF: Cognitive Level: Application fh fh TOP: Nursing Process: Assessment fh fh




5. The nurse is caring for a client who has left-
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sided paralysis as the result of a stroke and assesses a pressure injury on the cl i e n t‘s l ef t
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N R I G
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h ip . Which of the following is the most
B.C M
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appropriate nursing diagnosis fUo r t Sh is cNlienTt? O
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a. Impaired physical mobility related to decrease in muscle control (left- fh fh fh fh fh fh fh fh fh



sided paralysis) fh



b. Risk for impaired tissue integrity as evidenced by insufficient knowledge about p
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rotecting tissue integrity fh fh



c. Impaired skin integrity related to pressure over bony prominence (impaired cfh fh fh fh fh fh fh fh fh fh



irculation)
d. Ineffective tissue perfusion related to sedentary lifestyle fh fh fh fh fh fh




ANS: C
The client‘s major problem is the impaired skin integrity as demonstrated by the presence of a p
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ressure injury. The nurse is able to treat the cause of altered circulation and pressure by fre que
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ntly repositioning the client. Although left-sided weakness is a problem for the client,
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the nurse cannot treat the weakness. The ―risk for‖ diagnosis is not appropriate for this client, w
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ho already has impaired tissue integrity. The client does have ineffective tissue perfusion, b ut t
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he impaired skin integrity diagnosis indicates more clearly what the health problem is.
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DIF: f h f h Cognitive Level: Application fh fh TOP: f h f h Nursing Process: Diagnosis fh fh




6. The nurse caring for a client with an infection has a nursing diagnosis of deficient flui d
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volume related to excessive diaphoresis. Which of the following is an appropriate clie nt o
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utcome?
a. Client has a balanced intake and output. fh fh fh fh fh fh



b. Client‘s bedding is changed when it becomes damp. fh fh fh fh fh fh fh




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c. Client understands the need for increased fluid intake. fh fh fh fh fh fh fh



d. Client‘s skin remains cool and dry throughout hospitalization. fh fh fh fh fh fh fh




ANS: A
This statement gives measurable data showing resolution of the problem of deficient fluid vol u
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me that was identified in the nursing diagnosis statement. The other statements would not in dic
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ate that the problem of deficient fluid volume was resolved.
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DIF: Cognitive Level: Application fh fh TOP: Nursing Process: Planning fh fh




7. Which of the following represents a nursing activity that is carried out during the evaluatio n
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phase of the nursing process?
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a. Determining if interventions have been effective in meeting client outcomes fh fh fh fh fh fh fh fh fh



b. Documenting the nursing care plan in the progress notes in the medical record fh fh fh fh fh fh fh fh fh fh fh fh



c. Deciding whether the client‘s health problems have been completely resolved fh fh fh fh fh fh fh fh fh



d. Asking the client to evaluate whether the nursing care provided was satisfactory
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ANS: A
Evaluation consists of determining whether the desired client outcomes have been met and w h
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ether the nursing interventions were appropriate. The other responses do not describe the eva lu
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ation phase. fh




DIF: Cognitive Level: Comprehension fh fh TOP: Nursing Process: Evaluation fh fh




8. Which of the following would the nurse perform during the assessment phase of the nursing p
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rocess?
a. Obtains data with which to diagnose client problems fh fh fh fh fh fh fh



b. Uses client data to develoNp p R
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diagMnoses
c. Teaches interventions to relieve client health problems fh
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d. Assists the client to identify realistic outcomes to health problems
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ANS: A
During the assessment phase, the nurse gathers information about the client. The other respon s
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es are examples of the intervention, diagnosis, and planning phases of the nursing process.
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DIF: Cognitive Level: Knowledge fh fh TOP: Nursing Process: Assessment fh fh




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 fh fh fh fh fh fh



b. Risk for impaired tissue integrity related to sacral redness
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c. Ineffective coping related to insufficient sense of control. fh fh fh fh fh fh fh



d. Altered urinary elimination related to urinary tract infection fh fh fh fh fh fh fh




ANS: C
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes a
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client‘s response to a health problem that can be treated by nursing. The use of a medical diagn
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osis (as in the responses beginning ―Altered tissue perfusion‖ and ―Altered urinary eliminatio
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n‖) is not appropriate. The response beginning ―Risk for impaired tissue integrity‖ u ses the defin
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ing characteristics as the etiology.
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DIF: Cognitive Level: Comprehension fh fh TOP: Nursing Process: Diagnosis fh fh





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