TEST BANK
,Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. When caring for clients using evidence-informed practice, which of the following does the
nurse use?
a. Clinical judgement based on experience
b. Evidence from a clinical research study
c. The best available evidence to guide clinical expertise
d. Evaluation of data showing that the client outcomes are met
ANS: C
Evidence-informed nursing practice is a continuous interactive process involving the explicit,
conscientious, and judicious consideration of the best available evidence to provide care. Four
primary elements are: (a) clinical state, setting, and circumstances; (b) client preferences and
actions; (c) best research evidence; and (d) health care resources. Clinical judgement based on
the nurse’s clinical experience is part of EIP, but clinical decision making also should
incorporate current research and research-based guidelines. Evidence from one clinical
research study does not provide an adequate substantiation for interventions. Evaluation of
client outcomes is important, but interventions should be based on research from randomized
control studies with a large number of subjects.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning
2. Which of the following best e x p l ai ns th e nu rse s ’ pri m ar y use of the nursing process when
N R I G B.C M
providing care to clients? U S N T O
a. To explain nursing interventions to other health care professionals
b. As a problem-solving tool to identify and treat clients’ health care needs
c. As a scientific-based process of diagnosing the client’s health care problems
d. To establish nursing theory that incorporates the biopsychosocial nature of humans
ANS: B
The nursing process is an assertive problem-solving approach to the identification and
treatment of clients’ problems. Diagnosis is only one phase of the nursing process. The
primary use of the nursing process is in client care, not to establish nursing theory or explain
nursing interventions to other health care professionals.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation
3. The nurse is caring for a critically ill client in the intensive care unit and plans an every 2-hour
turning schedule to prevent skin breakdown. Which type of nursing function is demonstrated
with this turning schedule?
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: D
, When implementing collaborative nursing actions, the nurse is responsible primarily for
monitoring for complications of acute illness or providing care to prevent or treat
complications. Independent nursing actions are focused on health promotion, illness
prevention, and client advocacy. A dependent action would require a physician order to
implement. Cooperative nursing functions are not described as one of the formal nursing
functions.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
4. The nurse is caring for a client who has been admitted to the hospital for surgery and tells the
nurse, “I do not feel right about leaving my children with my neighbour.” Which action
should the nurse take next?
a. Reassure the client that these feelings are common for parents.
b. Have the client call the children to ensure that they are doing well.
c. Call the neighbour to determine whether adequate childcare is being provided.
d. Gather more data about the client’s feelings about the childcare arrangements.
ANS: D
Since a complete assessment is necessary in order to identify a problem and choose an
appropriate intervention, the nurse’s first action should be to obtain more information. The
other actions may be appropriate, but more assessment is needed before the best intervention
can be chosen.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
5. The nurse is caring for a client who has left-sided paralysis as the result of a stroke and
assesses a pressure injury on the client’s left hip. Which of the following is the most
appropriate nursing diagnosis fN
Uo rRt Sh I
i s cG B.C
NlienTt? OM
a. Impaired physical mobility related to decrease in muscle control (left-sided
paralysis)
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge about
protecting tissue integrity
c. Impaired skin integrity related to pressure over bony prominence (impaired
circulation)
d. Ineffective tissue perfusion related to sedentary lifestyle
ANS: C
The client’s major problem is the impaired skin integrity as demonstrated by the presence of a
pressure injury. The nurse is able to treat the cause of altered circulation and pressure by
frequently repositioning the client. Although left-sided weakness is a problem for the client,
the nurse cannot treat the weakness. The “risk for” diagnosis is not appropriate for this client,
who already has impaired tissue integrity. The client does have ineffective tissue perfusion,
but the impaired skin integrity diagnosis indicates more clearly what the health problem is.
DIF: Cognitive Level: Application TOP: Nursing Process: Diagnosis
6. The nurse caring for a client with an infection has a nursing diagnosis of deficient fluid
volume related to excessive diaphoresis. Which of the following is an appropriate client
outcome?
a. Client has a balanced intake and output.
b. Client’s bedding is changed when it becomes damp.
, c. Client understands the need for increased fluid intake.
d. Client’s skin remains cool and dry throughout hospitalization.
ANS: A
This statement gives measurable data showing resolution of the problem of deficient fluid
volume that was identified in the nursing diagnosis statement. The other statements would not
indicate that the problem of deficient fluid volume was resolved.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
7. Which of the following represents a nursing activity that is carried out during the evaluation
phase of the nursing process?
a. Determining if interventions have been effective in meeting client outcomes
b. Documenting the nursing care plan in the progress notes in the medical record
c. Deciding whether the client’s health problems have been completely resolved
d. Asking the client to evaluate whether the nursing care provided was satisfactory
ANS: A
Evaluation consists of determining whether the desired client outcomes have been met and
whether the nursing interventions were appropriate. The other responses do not describe the
evaluation phase.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Evaluation
8. Which of the following would the nurse perform during the assessment phase of the nursing
process?
a. Obtains data with which to diagnose client problems
b. Uses client data to develoN
p pR
U SIclient
r iori t y nGursiBng.dCiagM
noses
c. Teaches interventions to relieve N Thealth problems
d. Assists the client to identify realistic outcomes to health problems
ANS: A
During the assessment phase, the nurse gathers information about the client. The other
responses are examples of the intervention, diagnosis, and planning phases of the nursing
process.
DIF: Cognitive Level: Knowledge TOP: Nursing Process: Assessment
9. Which of the following is an example of a correctly written nursing diagnosis statement?
a. Altered tissue perfusion related to heart failure
b. Risk for impaired tissue integrity related to sacral redness
c. Ineffective coping related to insufficient sense of control.
d. Altered urinary elimination related to urinary tract infection
ANS: C
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes
a client’s response to a health problem that can be treated by nursing. The use of a medical
diagnosis (as in the responses beginning “Altered tissue perfusion” and “Altered urinary
elimination”) is not appropriate. The response beginning “Risk for impaired tissue integrity”
uses the defining characteristics as the etiology.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Diagnosis
,Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. When caring for clients using evidence-informed practice, which of the following does the
nurse use?
a. Clinical judgement based on experience
b. Evidence from a clinical research study
c. The best available evidence to guide clinical expertise
d. Evaluation of data showing that the client outcomes are met
ANS: C
Evidence-informed nursing practice is a continuous interactive process involving the explicit,
conscientious, and judicious consideration of the best available evidence to provide care. Four
primary elements are: (a) clinical state, setting, and circumstances; (b) client preferences and
actions; (c) best research evidence; and (d) health care resources. Clinical judgement based on
the nurse’s clinical experience is part of EIP, but clinical decision making also should
incorporate current research and research-based guidelines. Evidence from one clinical
research study does not provide an adequate substantiation for interventions. Evaluation of
client outcomes is important, but interventions should be based on research from randomized
control studies with a large number of subjects.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning
2. Which of the following best e x p l ai ns th e nu rse s ’ pri m ar y use of the nursing process when
N R I G B.C M
providing care to clients? U S N T O
a. To explain nursing interventions to other health care professionals
b. As a problem-solving tool to identify and treat clients’ health care needs
c. As a scientific-based process of diagnosing the client’s health care problems
d. To establish nursing theory that incorporates the biopsychosocial nature of humans
ANS: B
The nursing process is an assertive problem-solving approach to the identification and
treatment of clients’ problems. Diagnosis is only one phase of the nursing process. The
primary use of the nursing process is in client care, not to establish nursing theory or explain
nursing interventions to other health care professionals.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation
3. The nurse is caring for a critically ill client in the intensive care unit and plans an every 2-hour
turning schedule to prevent skin breakdown. Which type of nursing function is demonstrated
with this turning schedule?
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: D
, When implementing collaborative nursing actions, the nurse is responsible primarily for
monitoring for complications of acute illness or providing care to prevent or treat
complications. Independent nursing actions are focused on health promotion, illness
prevention, and client advocacy. A dependent action would require a physician order to
implement. Cooperative nursing functions are not described as one of the formal nursing
functions.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
4. The nurse is caring for a client who has been admitted to the hospital for surgery and tells the
nurse, “I do not feel right about leaving my children with my neighbour.” Which action
should the nurse take next?
a. Reassure the client that these feelings are common for parents.
b. Have the client call the children to ensure that they are doing well.
c. Call the neighbour to determine whether adequate childcare is being provided.
d. Gather more data about the client’s feelings about the childcare arrangements.
ANS: D
Since a complete assessment is necessary in order to identify a problem and choose an
appropriate intervention, the nurse’s first action should be to obtain more information. The
other actions may be appropriate, but more assessment is needed before the best intervention
can be chosen.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
5. The nurse is caring for a client who has left-sided paralysis as the result of a stroke and
assesses a pressure injury on the client’s left hip. Which of the following is the most
appropriate nursing diagnosis fN
Uo rRt Sh I
i s cG B.C
NlienTt? OM
a. Impaired physical mobility related to decrease in muscle control (left-sided
paralysis)
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge about
protecting tissue integrity
c. Impaired skin integrity related to pressure over bony prominence (impaired
circulation)
d. Ineffective tissue perfusion related to sedentary lifestyle
ANS: C
The client’s major problem is the impaired skin integrity as demonstrated by the presence of a
pressure injury. The nurse is able to treat the cause of altered circulation and pressure by
frequently repositioning the client. Although left-sided weakness is a problem for the client,
the nurse cannot treat the weakness. The “risk for” diagnosis is not appropriate for this client,
who already has impaired tissue integrity. The client does have ineffective tissue perfusion,
but the impaired skin integrity diagnosis indicates more clearly what the health problem is.
DIF: Cognitive Level: Application TOP: Nursing Process: Diagnosis
6. The nurse caring for a client with an infection has a nursing diagnosis of deficient fluid
volume related to excessive diaphoresis. Which of the following is an appropriate client
outcome?
a. Client has a balanced intake and output.
b. Client’s bedding is changed when it becomes damp.
, c. Client understands the need for increased fluid intake.
d. Client’s skin remains cool and dry throughout hospitalization.
ANS: A
This statement gives measurable data showing resolution of the problem of deficient fluid
volume that was identified in the nursing diagnosis statement. The other statements would not
indicate that the problem of deficient fluid volume was resolved.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
7. Which of the following represents a nursing activity that is carried out during the evaluation
phase of the nursing process?
a. Determining if interventions have been effective in meeting client outcomes
b. Documenting the nursing care plan in the progress notes in the medical record
c. Deciding whether the client’s health problems have been completely resolved
d. Asking the client to evaluate whether the nursing care provided was satisfactory
ANS: A
Evaluation consists of determining whether the desired client outcomes have been met and
whether the nursing interventions were appropriate. The other responses do not describe the
evaluation phase.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Evaluation
8. Which of the following would the nurse perform during the assessment phase of the nursing
process?
a. Obtains data with which to diagnose client problems
b. Uses client data to develoN
p pR
U SIclient
r iori t y nGursiBng.dCiagM
noses
c. Teaches interventions to relieve N Thealth problems
d. Assists the client to identify realistic outcomes to health problems
ANS: A
During the assessment phase, the nurse gathers information about the client. The other
responses are examples of the intervention, diagnosis, and planning phases of the nursing
process.
DIF: Cognitive Level: Knowledge TOP: Nursing Process: Assessment
9. Which of the following is an example of a correctly written nursing diagnosis statement?
a. Altered tissue perfusion related to heart failure
b. Risk for impaired tissue integrity related to sacral redness
c. Ineffective coping related to insufficient sense of control.
d. Altered urinary elimination related to urinary tract infection
ANS: C
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes
a client’s response to a health problem that can be treated by nursing. The use of a medical
diagnosis (as in the responses beginning “Altered tissue perfusion” and “Altered urinary
elimination”) is not appropriate. The response beginning “Risk for impaired tissue integrity”
uses the defining characteristics as the etiology.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Diagnosis
