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