Medical-Surgical Nursing in Canada 5th Edition Lewi Test Bank
h/ h/ h/ h/ h/ h/ h/ h/
NURSINGTB.COM
, Medical-Surgical Nursing in Canada 5th Edition Lewi Test Bank h/ h/ h/ h/ h/ h/ h/ h/
Chapter 01: Introduction to Medical-
h/ h/ h/ h/
Surgical Nursing Practice in Canada Lewis: Medical-
h/ h/ h/ h/ h/ h/
Surgical Nursing in Canada, 5th Canadian Edition
h/ h/ h/ h/ h/ h/
MULTIPLE CHOICE h/
1. When caring for clients using evidence-
h/ h/ h/ h/ h/
informed practice, which of the following does the nurse use?
h/ h/ h/ h/ h/ h/ h/ h/ h/
a. Clinical judgement based on experience h/ h/ h/ h/
b. Evidence from a clinical research study h/ h/ h/ h/ h/
c. The best available evidence to guide clinical expertise
h/ h/ h/ h/ h/ h/ h/
d. Evaluation of data showing that the client outcomes are met h/ h/ h/ h/ h/ h/ h/ h/ h/
ANS: C h /
Evidence-
informed nursing practice is a continuous interactive process involving the explicit, conscienti
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
ous, and judicious consideration of the best available evidence to provide care. Four primary el
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
ements are: (a) clinical state, setting, and circumstances; (b) client preferences and actions; (c
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
) best research evidence; and (d) health care resources. Clinical judgement based on the nurse‘s
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
clinical experience is part of EIP, but clinical decision making also should incorporate curren
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
t research and research-
h/ h/ h/
based guidelines. Evidence from one clinical research study does not provide an adequate sub
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
stantiation for interventions. Evaluation of client outcomes is important, but interventions sho
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
uld be based on research from randomized control studies with a large number of subjects.
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
DIF: Cognitive Level: Comprehension h/ h/ TOP: Nursing Process: Planning h / h/ h/
2. Which of the following best e xpl a ins the nu r s e s ‘ primary use of the nursing process when p
N R I G B . C M
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h / h/ h/ h/ h/ h/ h/ h/
roviding care to clients? h/ h/ h/
USNT h/ h/ h/ O
a. To explain nursing interventions to other health care professionals
h/ h/ h/ h/ h/ h/ h/ h/
b. As a problem-solving tool to identify and treat clients‘ health care needs
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
c. As a scientific-based process of diagnosing the client‘s health care problems
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
d. To establish nursing theory that incorporates the biopsychosocial nature of humans
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
ANS: B h /
The nursing process is an assertive problem-
h/ h/ h/ h/ h/ h/
solving approach to the identification and treatment of clients‘ problems. Diagnosis is only o
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
ne phase of the nursing process. The primary use of the nursing process is in client care, not to
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
establish nursing theory or explain nursing interventions to other health care professionals.
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
DIF: Cognitive Level: Comprehension h/ h/ TOP: Nursing Process: Implementation
h / h/ h/
3. The nurse is caring for a critically ill client in the intensive care unit and plans an every 2-
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
hour turning schedule to prevent skin breakdown. Which type of nursing function is demonst
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
rated with this turning schedule?
h/ h/ h/ h/
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: D h /
NURSINGTB.COM
, Medical-Surgical Nursing in Canada 5th Edition Lewi Test Bank h/ h/ h/ h/ h/ h/ h/ h/
When implementing collaborative nursing actions, the nurse is responsible primarily for monit
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
oring for complications of acute illness or providing care to prevent or treat complications. In
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
dependent nursing actions are focused on health promotion, illness prevention, and client adv
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
ocacy. A dependent action would require a physician order to implement. Cooperative nursin
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
g functions are not described as one of the formal nursing functions.
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
DIF: Cognitive Level: Application h/ h/ TOP: Nursing Process: Implementation
h / h/ h/
4. The nurse is caring for a client who has been admitted to the hospital for surgery and tells the
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
nurse, ―I do not feel right about leaving my children with my neighbour.‖ Which action sh
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
ould the nurse take next? h/ h/ h/ h/
a. Reassure the client that these feelings are common for parents. h/ h/ h/ h/ h/ h/ h/ h/ h/
b. Have the client call the children to ensure that they are doing well.
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
c. Call the neighbour to determine whether adequate childcare is being provided.
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
d. Gather more data about the client‘s feelings about the childcare arrangements.
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
ANS: D h /
Since a complete assessment is necessary in order to identify a problem and choose an appro
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
priate intervention, the nurse‘s first action should be to obtain more information. The other ac
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
tions may be appropriate, but more assessment is needed before the best intervention can be ch
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
osen.
DIF: Cognitive Level: Application h/ h/ TOP: Nursing Process: Assessment
h / h/ h/
5. The nurse is caring for a client who has left-
h/ h/ h/ h/ h/ h/ h/ h/ h/
sided paralysis as the result of a stroke and assesses a pressure injury on the clie nt‘s lef
N Ris theImostG appropriate
B.C Mnursing diagnosis f Uo r t Sh is cNlienT
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
t h ip . W hich of the following
h/ h/ h
/ h/ h/ h/ h/ h/ h/
h /
h/
h /
h/ h/
h / h /
h/
/
h /
h h /
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
t? h/ O
a. Impaired physical mobility related to decrease in muscle control (left-sided h/ h/ h/ h/ h/ h/ h/ h/ h/
paralysis)
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge about
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
protecting tissue integrity h/ h/
c. Impaired skin integrity related to pressure over bony prominence (impaired h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
circulation)
d. Ineffective tissue perfusion related to sedentary lifestyle h/ h/ h/ h/ h/ h/
ANS: C h /
The client‘s major problem is the impaired skin integrity as demonstrated by the presence of a
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
pressure injury. The nurse is able to treat the cause of altered circulation and pressure by freq
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
uently repositioning the client. Although left-
h/ h/ h/ h/ h/
sided weakness is a problem for the client, the nurse cannot treat the weakness. The ―risk for‖
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h
diagnosis is not appropriate for this client, who already has impaired tissue integrity. The clien
/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
t does have ineffective tissue perfusion, but the impaired skin integrity diagnosis indicates mo
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
re clearly what the health problem is.
h/ h/ h/ h/ h/ h/
DIF: Cognitive Level: Application h/ h/ TOP: Nursing Process: Diagnosish / h/ h/
6. The nurse caring for a client with an infection has a nursing diagnosis of deficient fluid
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h
volume related to excessive diaphoresis. Which of the following is an appropriate client
/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
outcome?
h/
a. Client has a balanced intake and output. h/ h/ h/ h/ h/ h/
b. Client‘s bedding is changed when it becomes damp. h/ h/ h/ h/ h/ h/ h/
NURSINGTB.COM
, Medical-Surgical Nursing in Canada 5th Edition Lewi Test Bank h/ h/ h/ h/ h/ h/ h/ h/
c. Client understands the need for increased fluid intake.
h/ h/ h/ h/ h/ h/ h/
d. Client‘s skin remains cool and dry throughout hospitalization.
h/ h/ h/ h/ h/ h/ h/
ANS: A h /
This statement gives measurable data showing resolution of the problem of deficient fluid vol
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
ume that was identified in the nursing diagnosis statement. The other statements would not indi
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
cate that the problem of deficient fluid volume was resolved.
h/ h/ h/ h/ h/ h/ h/ h/ h/
DIF: Cognitive Level: Application h/ h/ TOP: Nursing Process: Planning h / h/ h/
7. Which of the following represents a nursing activity that is carried out during the evaluation
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
phase of the nursing process?
h/ h/ h/ h/
a. Determining if interventions have been effective in meeting client outcomes h/ h/ h/ h/ h/ h/ h/ h/ h/
b. Documenting the nursing care plan in the progress notes in the medical record h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
c. Deciding whether the client‘s health problems have been completely resolved
h/ h/ h/ h/ h/ h/ h/ h/ h/
d. Asking the client to evaluate whether the nursing care provided was satisfactory
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
ANS: A h /
Evaluation consists of determining whether the desired client outcomes have been met and w
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
hether the nursing interventions were appropriate. The other responses do not describe the eval
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
uation phase. h/
DIF: Cognitive Level: Comprehension h/ h/ TOP: Nursing Process: Evaluation
h / h/ h/
8. Which of the following would the nurse perform during the assessment phase of the nursing
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
process?
a. Obtains data with which to diagnose client problems h/ h/ h/ h/ h/ h/ h/
b. Uses client data to develoNp p R
ri o riIt y nGursB
U S N T in.
h/ gC
diagMnoses
c. Teaches interventions to relieve client health problems h/
h/ h/ h/
h/
h/
h/
h/ h/
h/
h/ h /
h/
h/
h/
h/
d. Assists the client to identify realistic outcomes to health problems
h/ h/ h/ h/ h/ h/ h/ h/ h/
ANS: A h /
During the assessment phase, the nurse gathers information about the client. The other respon
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
ses are examples of the intervention, diagnosis, and planning phases of the nursing process.
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
DIF: Cognitive Level: Knowledge h/ h/ TOP: Nursing Process: Assessment
h / h/ h/
9. Which of the following is an example of a correctly written nursing diagnosis statement?
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
a. Altered tissue perfusion related to heart failure h/ h/ h/ h/ h/ h/
b. Risk for impaired tissue integrity related to sacral redness
h/ h/ h/ h/ h/ h/ h/ h/
c. Ineffective coping related to insufficient sense of control. h/ h/ h/ h/ h/ h/ h/
d. Altered urinary elimination related to urinary tract infection
h/ h/ h/ h/ h/ h/ h/
ANS: C h /
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
a client‘s response to a health problem that can be treated by nursing. The use of a medical d
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
iagnosis (as in the responses beginning ―Altered tissue perfusion‖ and ―Altered urinary elim
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
ination‖) is not appropriate. The response beginning ―Risk for impaired tissue integrity‖ uses
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
the defining characteristics as the etiology.
h/ h/ h/ h/ h/ h/
DIF: Cognitive Level: Comprehension h/ h/ TOP: Nursing Process: Diagnosish / h/ h/
NURSINGTB.COM
h/ h/ h/ h/ h/ h/ h/ h/
NURSINGTB.COM
, Medical-Surgical Nursing in Canada 5th Edition Lewi Test Bank h/ h/ h/ h/ h/ h/ h/ h/
Chapter 01: Introduction to Medical-
h/ h/ h/ h/
Surgical Nursing Practice in Canada Lewis: Medical-
h/ h/ h/ h/ h/ h/
Surgical Nursing in Canada, 5th Canadian Edition
h/ h/ h/ h/ h/ h/
MULTIPLE CHOICE h/
1. When caring for clients using evidence-
h/ h/ h/ h/ h/
informed practice, which of the following does the nurse use?
h/ h/ h/ h/ h/ h/ h/ h/ h/
a. Clinical judgement based on experience h/ h/ h/ h/
b. Evidence from a clinical research study h/ h/ h/ h/ h/
c. The best available evidence to guide clinical expertise
h/ h/ h/ h/ h/ h/ h/
d. Evaluation of data showing that the client outcomes are met h/ h/ h/ h/ h/ h/ h/ h/ h/
ANS: C h /
Evidence-
informed nursing practice is a continuous interactive process involving the explicit, conscienti
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
ous, and judicious consideration of the best available evidence to provide care. Four primary el
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
ements are: (a) clinical state, setting, and circumstances; (b) client preferences and actions; (c
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
) best research evidence; and (d) health care resources. Clinical judgement based on the nurse‘s
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
clinical experience is part of EIP, but clinical decision making also should incorporate curren
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
t research and research-
h/ h/ h/
based guidelines. Evidence from one clinical research study does not provide an adequate sub
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
stantiation for interventions. Evaluation of client outcomes is important, but interventions sho
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
uld be based on research from randomized control studies with a large number of subjects.
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
DIF: Cognitive Level: Comprehension h/ h/ TOP: Nursing Process: Planning h / h/ h/
2. Which of the following best e xpl a ins the nu r s e s ‘ primary use of the nursing process when p
N R I G B . C M
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h / h/ h/ h/ h/ h/ h/ h/
roviding care to clients? h/ h/ h/
USNT h/ h/ h/ O
a. To explain nursing interventions to other health care professionals
h/ h/ h/ h/ h/ h/ h/ h/
b. As a problem-solving tool to identify and treat clients‘ health care needs
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
c. As a scientific-based process of diagnosing the client‘s health care problems
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
d. To establish nursing theory that incorporates the biopsychosocial nature of humans
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
ANS: B h /
The nursing process is an assertive problem-
h/ h/ h/ h/ h/ h/
solving approach to the identification and treatment of clients‘ problems. Diagnosis is only o
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
ne phase of the nursing process. The primary use of the nursing process is in client care, not to
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
establish nursing theory or explain nursing interventions to other health care professionals.
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
DIF: Cognitive Level: Comprehension h/ h/ TOP: Nursing Process: Implementation
h / h/ h/
3. The nurse is caring for a critically ill client in the intensive care unit and plans an every 2-
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
hour turning schedule to prevent skin breakdown. Which type of nursing function is demonst
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
rated with this turning schedule?
h/ h/ h/ h/
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: D h /
NURSINGTB.COM
, Medical-Surgical Nursing in Canada 5th Edition Lewi Test Bank h/ h/ h/ h/ h/ h/ h/ h/
When implementing collaborative nursing actions, the nurse is responsible primarily for monit
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
oring for complications of acute illness or providing care to prevent or treat complications. In
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
dependent nursing actions are focused on health promotion, illness prevention, and client adv
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
ocacy. A dependent action would require a physician order to implement. Cooperative nursin
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
g functions are not described as one of the formal nursing functions.
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
DIF: Cognitive Level: Application h/ h/ TOP: Nursing Process: Implementation
h / h/ h/
4. The nurse is caring for a client who has been admitted to the hospital for surgery and tells the
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
nurse, ―I do not feel right about leaving my children with my neighbour.‖ Which action sh
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
ould the nurse take next? h/ h/ h/ h/
a. Reassure the client that these feelings are common for parents. h/ h/ h/ h/ h/ h/ h/ h/ h/
b. Have the client call the children to ensure that they are doing well.
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
c. Call the neighbour to determine whether adequate childcare is being provided.
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
d. Gather more data about the client‘s feelings about the childcare arrangements.
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
ANS: D h /
Since a complete assessment is necessary in order to identify a problem and choose an appro
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
priate intervention, the nurse‘s first action should be to obtain more information. The other ac
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
tions may be appropriate, but more assessment is needed before the best intervention can be ch
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
osen.
DIF: Cognitive Level: Application h/ h/ TOP: Nursing Process: Assessment
h / h/ h/
5. The nurse is caring for a client who has left-
h/ h/ h/ h/ h/ h/ h/ h/ h/
sided paralysis as the result of a stroke and assesses a pressure injury on the clie nt‘s lef
N Ris theImostG appropriate
B.C Mnursing diagnosis f Uo r t Sh is cNlienT
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
t h ip . W hich of the following
h/ h/ h
/ h/ h/ h/ h/ h/ h/
h /
h/
h /
h/ h/
h / h /
h/
/
h /
h h /
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
t? h/ O
a. Impaired physical mobility related to decrease in muscle control (left-sided h/ h/ h/ h/ h/ h/ h/ h/ h/
paralysis)
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge about
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
protecting tissue integrity h/ h/
c. Impaired skin integrity related to pressure over bony prominence (impaired h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
circulation)
d. Ineffective tissue perfusion related to sedentary lifestyle h/ h/ h/ h/ h/ h/
ANS: C h /
The client‘s major problem is the impaired skin integrity as demonstrated by the presence of a
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
pressure injury. The nurse is able to treat the cause of altered circulation and pressure by freq
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
uently repositioning the client. Although left-
h/ h/ h/ h/ h/
sided weakness is a problem for the client, the nurse cannot treat the weakness. The ―risk for‖
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h
diagnosis is not appropriate for this client, who already has impaired tissue integrity. The clien
/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
t does have ineffective tissue perfusion, but the impaired skin integrity diagnosis indicates mo
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
re clearly what the health problem is.
h/ h/ h/ h/ h/ h/
DIF: Cognitive Level: Application h/ h/ TOP: Nursing Process: Diagnosish / h/ h/
6. The nurse caring for a client with an infection has a nursing diagnosis of deficient fluid
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h
volume related to excessive diaphoresis. Which of the following is an appropriate client
/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
outcome?
h/
a. Client has a balanced intake and output. h/ h/ h/ h/ h/ h/
b. Client‘s bedding is changed when it becomes damp. h/ h/ h/ h/ h/ h/ h/
NURSINGTB.COM
, Medical-Surgical Nursing in Canada 5th Edition Lewi Test Bank h/ h/ h/ h/ h/ h/ h/ h/
c. Client understands the need for increased fluid intake.
h/ h/ h/ h/ h/ h/ h/
d. Client‘s skin remains cool and dry throughout hospitalization.
h/ h/ h/ h/ h/ h/ h/
ANS: A h /
This statement gives measurable data showing resolution of the problem of deficient fluid vol
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
ume that was identified in the nursing diagnosis statement. The other statements would not indi
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
cate that the problem of deficient fluid volume was resolved.
h/ h/ h/ h/ h/ h/ h/ h/ h/
DIF: Cognitive Level: Application h/ h/ TOP: Nursing Process: Planning h / h/ h/
7. Which of the following represents a nursing activity that is carried out during the evaluation
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
phase of the nursing process?
h/ h/ h/ h/
a. Determining if interventions have been effective in meeting client outcomes h/ h/ h/ h/ h/ h/ h/ h/ h/
b. Documenting the nursing care plan in the progress notes in the medical record h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
c. Deciding whether the client‘s health problems have been completely resolved
h/ h/ h/ h/ h/ h/ h/ h/ h/
d. Asking the client to evaluate whether the nursing care provided was satisfactory
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
ANS: A h /
Evaluation consists of determining whether the desired client outcomes have been met and w
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
hether the nursing interventions were appropriate. The other responses do not describe the eval
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
uation phase. h/
DIF: Cognitive Level: Comprehension h/ h/ TOP: Nursing Process: Evaluation
h / h/ h/
8. Which of the following would the nurse perform during the assessment phase of the nursing
h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/ h/
process?
a. Obtains data with which to diagnose client problems h/ h/ h/ h/ h/ h/ h/
b. Uses client data to develoNp p R
ri o riIt y nGursB
U S N T in.
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diagMnoses
c. Teaches interventions to relieve client health problems h/
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d. Assists the client to identify realistic outcomes to health problems
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ANS: A h /
During the assessment phase, the nurse gathers information about the client. The other respon
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ses are examples of the intervention, diagnosis, and planning phases of the nursing process.
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DIF: Cognitive Level: Knowledge h/ h/ TOP: Nursing Process: Assessment
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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 h/ h/ h/ h/ h/ h/
b. Risk for impaired tissue integrity related to sacral redness
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c. Ineffective coping related to insufficient sense of control. h/ h/ h/ h/ h/ h/ h/
d. Altered urinary elimination related to urinary tract infection
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ANS: C h /
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes
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a client‘s response to a health problem that can be treated by nursing. The use of a medical d
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iagnosis (as in the responses beginning ―Altered tissue perfusion‖ and ―Altered urinary elim
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ination‖) is not appropriate. The response beginning ―Risk for impaired tissue integrity‖ uses
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the defining characteristics as the etiology.
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DIF: Cognitive Level: Comprehension h/ h/ TOP: Nursing Process: Diagnosish / h/ h/
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