TEST BANK
Lewis's Medical Surgical Nursing in Canada 5th Edition Jeffrey Kwong;
Courtney Reinisch; Jane Tyerman; Shelley Cobbett; Debra Hagler;
Mariann Harding; Dott
,Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada
Tyerman: Lewis’s Medical-Surgical Nursing in Canada, 5th Edition
MULTIPLE CHOICE
1. The nurse is caring for a patient with a new diagnosis of pneumonia and explains to the
patient that together they will plan the patient’s care and set goals for discharge. The patient
asks, “How is that different from what the doctor does?” Which response by the nurse is most
appropriate?
a. “The role of the nurse is to administer medications and other treatments prescribed by
your doctor.”
b. “The nurse’s job is to help the doctor by collecting data and communicating when there
are problems.”
c. “Nurses perform many of the procedures done by physicians, but nurses are here in the
hospital for a longer time than doctors.”
d. “In addition to caring for you while you are sick, the nurses will assist you to develop an
individualized plan to maintain your health.”
ANS: D
This response is consistent with the Canadian Nurses Association (CNA) definition of
nursing. Registered nurses are self-regulated health care professionals who work
autonomously and in collaboration with others. RNs enable individuals, families, groups,
communities and populations to achieve their optimal level of health. RNs coordinate health
care, deliver direct services, and support patients in their self-care decisions and actions in
situations of health, illness, injury, and disability in all stages of life. The other responses
describe some of the dependent and collaborative functions of the nursing role but do not
accurately describe the nurse’s role in the health care system.
DIF: Cognitive Level: Comprehension TOP: Nursing Process:
Implementation MSC: NCLEX: Safe and Effective Care Environment
2. When caring for patients 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 patient 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) patient 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
, patient 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
MSC: NCLEX: Safe and Effective Care Environment
3. Which of the following best explains the nurse’s primary use of the nursing process when
providing care to patients?
a. To explain nursing interventions to other health care professionals
b. As a problem-solving tool to identify and treat patients’ health care needs
c. As a scientific-based process of diagnosing the patient’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 patients’ problems. Diagnosis is only one phase of the nursing process. The
primary use of the nursing process is in patient care, not to establish nursing theory or explain
nursing interventions to other health care professionals.
DIF: Cognitive Level: Comprehension TOP: Nursing Process:
Implementation MSC: NCLEX: Safe and Effective Care Environment
4. The nurse is caring for a critically ill patient 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 patient 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 MSC: NCLEX: Safe and Effective Care Environment
5. The nurse is caring for a patient who has been admitted to the hospital for surgery and tells
the nurse, “I do not feel right about leaving my children with my neighbor.” Which action
should the nurse take next?
a. Reassure the patient that these feelings are common for parents.
b. Have the patient call the children to ensure that they are doing well.
c. Call the neighbor to determine whether adequate childcare is being provided.
d. Gather more data about the patient’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
MSC: NCLEX: Psychosocial Integrity
6. The nurse is caring for a patient who has left-sided paralysis as the result of a stroke and
assesses a pressure injury on the patient’s left hip. Which of the following is the most
appropriate nursing diagnosis for this patient?
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 peripheral tissue perfusion related to sedentary lifestyle
ANS: C The patient’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 impaired circulation and
pressure over bony prominence by frequently repositioning the patient. Although left-sided
weakness is a problem for the patient, the nurse cannot treat the weakness. The “risk for”
diagnosis is not appropriate for this patient, who already has impaired tissue integrity. The
patient does have ineffective peripheral tissue perfusion, but the impaired skin integrity
diagnosis indicates more clearly what the health problem is.
DIF: Cognitive Level: Application TOP: Nursing Process: Diagnosis
MSC: NCLEX: Physiological Integrity
7. The nurse caring for a patient with an infection has a nursing diagnosis of deficient fluid
volume related to excessive fluid loss through normal route (diaphoresis). Which of the
following is an appropriate patient outcome?
a. Patient has a balanced intake and output.
b. Patient’s bedding is changed when it becomes damp.
c. Patient understands the need for increased fluid intake.
d. Patient’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
MSC: NCLEX: Physiological Integrity
8. Which of the following represents a nursing activity that is carried out during the evaluation
phase of the nursing process?
Lewis's Medical Surgical Nursing in Canada 5th Edition Jeffrey Kwong;
Courtney Reinisch; Jane Tyerman; Shelley Cobbett; Debra Hagler;
Mariann Harding; Dott
,Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada
Tyerman: Lewis’s Medical-Surgical Nursing in Canada, 5th Edition
MULTIPLE CHOICE
1. The nurse is caring for a patient with a new diagnosis of pneumonia and explains to the
patient that together they will plan the patient’s care and set goals for discharge. The patient
asks, “How is that different from what the doctor does?” Which response by the nurse is most
appropriate?
a. “The role of the nurse is to administer medications and other treatments prescribed by
your doctor.”
b. “The nurse’s job is to help the doctor by collecting data and communicating when there
are problems.”
c. “Nurses perform many of the procedures done by physicians, but nurses are here in the
hospital for a longer time than doctors.”
d. “In addition to caring for you while you are sick, the nurses will assist you to develop an
individualized plan to maintain your health.”
ANS: D
This response is consistent with the Canadian Nurses Association (CNA) definition of
nursing. Registered nurses are self-regulated health care professionals who work
autonomously and in collaboration with others. RNs enable individuals, families, groups,
communities and populations to achieve their optimal level of health. RNs coordinate health
care, deliver direct services, and support patients in their self-care decisions and actions in
situations of health, illness, injury, and disability in all stages of life. The other responses
describe some of the dependent and collaborative functions of the nursing role but do not
accurately describe the nurse’s role in the health care system.
DIF: Cognitive Level: Comprehension TOP: Nursing Process:
Implementation MSC: NCLEX: Safe and Effective Care Environment
2. When caring for patients 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 patient 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) patient 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
, patient 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
MSC: NCLEX: Safe and Effective Care Environment
3. Which of the following best explains the nurse’s primary use of the nursing process when
providing care to patients?
a. To explain nursing interventions to other health care professionals
b. As a problem-solving tool to identify and treat patients’ health care needs
c. As a scientific-based process of diagnosing the patient’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 patients’ problems. Diagnosis is only one phase of the nursing process. The
primary use of the nursing process is in patient care, not to establish nursing theory or explain
nursing interventions to other health care professionals.
DIF: Cognitive Level: Comprehension TOP: Nursing Process:
Implementation MSC: NCLEX: Safe and Effective Care Environment
4. The nurse is caring for a critically ill patient 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 patient 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 MSC: NCLEX: Safe and Effective Care Environment
5. The nurse is caring for a patient who has been admitted to the hospital for surgery and tells
the nurse, “I do not feel right about leaving my children with my neighbor.” Which action
should the nurse take next?
a. Reassure the patient that these feelings are common for parents.
b. Have the patient call the children to ensure that they are doing well.
c. Call the neighbor to determine whether adequate childcare is being provided.
d. Gather more data about the patient’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
MSC: NCLEX: Psychosocial Integrity
6. The nurse is caring for a patient who has left-sided paralysis as the result of a stroke and
assesses a pressure injury on the patient’s left hip. Which of the following is the most
appropriate nursing diagnosis for this patient?
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 peripheral tissue perfusion related to sedentary lifestyle
ANS: C The patient’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 impaired circulation and
pressure over bony prominence by frequently repositioning the patient. Although left-sided
weakness is a problem for the patient, the nurse cannot treat the weakness. The “risk for”
diagnosis is not appropriate for this patient, who already has impaired tissue integrity. The
patient does have ineffective peripheral tissue perfusion, but the impaired skin integrity
diagnosis indicates more clearly what the health problem is.
DIF: Cognitive Level: Application TOP: Nursing Process: Diagnosis
MSC: NCLEX: Physiological Integrity
7. The nurse caring for a patient with an infection has a nursing diagnosis of deficient fluid
volume related to excessive fluid loss through normal route (diaphoresis). Which of the
following is an appropriate patient outcome?
a. Patient has a balanced intake and output.
b. Patient’s bedding is changed when it becomes damp.
c. Patient understands the need for increased fluid intake.
d. Patient’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
MSC: NCLEX: Physiological Integrity
8. Which of the following represents a nursing activity that is carried out during the evaluation
phase of the nursing process?
