Medical-Surgical Nursing in Canada 5th Edition Lewi Test Bank
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NURSINGTB.COM
, Medical-Surgical Nursing in Canada 5th Edition Lewi Test Bank /{ /{ /{ /{ /{ /{ /{ /{
Chapter 01: Introduction to Medical-
/{ /{ /{ /{
Surgical Nursing Practice in Canada Lewis: Medical-
/{ /{ /{ /{ /{ /{
Surgical Nursing in Canada, 5th 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, conscienti
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
ous, and judicious consideration of the best available evidence to provide care. Four primary el
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
ements 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 sub
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
stantiation for interventions. Evaluation of client outcomes is important, but interventions sho
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
uld 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 expl a ins the nu r s e s ‘ primary use of the nursing process when pr
/{
N R I G B .C M/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ / { /{ /{ /{ /{ /{ /{ /{
oviding care to clients? /{ /{ /{
USNT /{ /{ /{ 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 on
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
e phase of the nursing process. The primary use of the nursing process is in client care, not to e
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
stablish 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 demonstr
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
ated with this turning schedule?
/{ /{ /{ /{
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: D / {
NURSINGTB.COM
, Medical-Surgical Nursing in Canada 5th Edition Lewi Test Bank /{ /{ /{ /{ /{ /{ /{ /{
When implementing collaborative nursing actions, the nurse is responsible primarily for monit
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
oring for complications of acute illness or providing care to prevent or treat complications. In
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
dependent nursing actions are focused on health promotion, illness prevention, and client adv
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
ocacy. 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 sho
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
uld 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 approp
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
riate intervention, the nurse‘s first action should be to obtain more information. The other acti
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
ons may be appropriate, but more assessment is needed before the best intervention can be chos
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
en.
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 clie nt‘s left
N isRtheI mostGappropriate
B.C nursing
M diagnosis f Uo r t Sh is cNlienTt
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
h ip . Which of the following
/{ /{ /{ /{ /{ /{ /{ /{ /{
/ {
/{ /{
/ {
/{
/ {
/{
/ { {
/ {
/ / {
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
? O
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 p
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
ressure injury. The nurse is able to treat the cause of altered circulation and pressure by frequ
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
ently 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 clien
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
t does have ineffective tissue perfusion, but the impaired skin integrity diagnosis indicates mo
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
re 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. /{ /{ /{ /{ /{ /{ /{
NURSINGTB.COM
, Medical-Surgical Nursing in Canada 5th Edition Lewi Test Bank /{ /{ /{ /{ /{ /{ /{ /{
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 vol
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
ume that was identified in the nursing diagnosis statement. The other statements would not indi
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
cate 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 w
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
hether the nursing interventions were appropriate. The other responses do not describe the eval
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
uation 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 develoNp p R
ri o riIt y nGursB
/{
U S N T in. gC
diagMnoses
c. Teaches interventions to relieve client health 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 respon
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
ses 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 d
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
iagnosis (as in the responses beginning ―Altered tissue perfusion‖ and ―Altered urinary elim
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
ination‖) 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 / { /{ /{
NURSINGTB.COM
/{ /{ /{ /{ /{ /{ /{ /{
NURSINGTB.COM
, Medical-Surgical Nursing in Canada 5th Edition Lewi Test Bank /{ /{ /{ /{ /{ /{ /{ /{
Chapter 01: Introduction to Medical-
/{ /{ /{ /{
Surgical Nursing Practice in Canada Lewis: Medical-
/{ /{ /{ /{ /{ /{
Surgical Nursing in Canada, 5th 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, conscienti
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
ous, and judicious consideration of the best available evidence to provide care. Four primary el
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
ements 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 sub
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
stantiation for interventions. Evaluation of client outcomes is important, but interventions sho
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
uld 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 expl a ins the nu r s e s ‘ primary use of the nursing process when pr
/{
N R I G B .C M/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ / { /{ /{ /{ /{ /{ /{ /{
oviding care to clients? /{ /{ /{
USNT /{ /{ /{ 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 on
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
e phase of the nursing process. The primary use of the nursing process is in client care, not to e
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
stablish 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 demonstr
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
ated with this turning schedule?
/{ /{ /{ /{
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: D / {
NURSINGTB.COM
, Medical-Surgical Nursing in Canada 5th Edition Lewi Test Bank /{ /{ /{ /{ /{ /{ /{ /{
When implementing collaborative nursing actions, the nurse is responsible primarily for monit
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
oring for complications of acute illness or providing care to prevent or treat complications. In
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
dependent nursing actions are focused on health promotion, illness prevention, and client adv
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
ocacy. 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 sho
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
uld 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 approp
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
riate intervention, the nurse‘s first action should be to obtain more information. The other acti
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
ons may be appropriate, but more assessment is needed before the best intervention can be chos
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
en.
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 clie nt‘s left
N isRtheI mostGappropriate
B.C nursing
M diagnosis f Uo r t Sh is cNlienTt
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
h ip . Which of the following
/{ /{ /{ /{ /{ /{ /{ /{ /{
/ {
/{ /{
/ {
/{
/ {
/{
/ { {
/ {
/ / {
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
? O
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 p
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
ressure injury. The nurse is able to treat the cause of altered circulation and pressure by frequ
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
ently 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 clien
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
t does have ineffective tissue perfusion, but the impaired skin integrity diagnosis indicates mo
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
re 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. /{ /{ /{ /{ /{ /{ /{
NURSINGTB.COM
, Medical-Surgical Nursing in Canada 5th Edition Lewi Test Bank /{ /{ /{ /{ /{ /{ /{ /{
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 vol
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
ume that was identified in the nursing diagnosis statement. The other statements would not indi
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
cate 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 w
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
hether the nursing interventions were appropriate. The other responses do not describe the eval
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
uation 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 develoNp p R
ri o riIt y nGursB
/{
U S N T in. gC
diagMnoses
c. Teaches interventions to relieve client health 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 respon
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
ses are examples of the intervention, diagnosis, and planning phases of the nursing process.
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DIF: Cognitive Level: Knowledge /{ /{ TOP: Nursing Process: Assessment/ { /{ /{
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 /{ /{ /{ /{ /{ /{
b. Risk for impaired tissue integrity related to sacral redness
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c. Ineffective coping related to insufficient sense of control. /{ /{ /{ /{ /{ /{ /{
d. Altered urinary elimination related to urinary tract infection
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ANS: C / {
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
/{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{ /{
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 /{ /{ TOP: Nursing Process: Diagnosis / { /{ /{
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