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Medical-


Chapter 01: Introduction to Medical-
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Surgical Nursing Practice in Canada Lewis: Medical-
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Surgical Nursing in Canada, 5th Canadian Edition
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MULTIPLE CHOICE Xt




1. When caring for clients using evidence-
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informed practice, which of the following does the nurse use?
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a. Clinical judgement based on experience
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, Medical-
b. Evidence from a clinical research study Xt Xt Xt Xt Xt


c. The best available evidence to guide clinical expertise
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d. Evaluation of data showing that the client outcomes are met Xt Xt Xt Xt Xt Xt Xt Xt Xt




ANS: C
Evidence-
informed nursing practice is a continuous interactive process involving the explicit, conscie
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nt ious, and judicious consideration of the best available evidence to provide care. Four pri
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mary elements are: (a) clinical state, setting, and circumstances; (b) client preferences and a
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ctions;
(c) best research evidence; and (d) health care resources. Clinical judgement based on the n
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urs e‘s clinical experience is part of EIP, but clinical decision making also should incorpora
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te cur rent research and research-
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based guidelines. Evidence from one clinical research study does not provide an adequate s
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ub stantiation for interventions. Evaluation of client outcomes is important, but intervention
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s sho uld be based on research from randomized control studies with a large number of sub
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jects.

DIF: X t X t Cognitive Level: Comprehension Xt Xt X t X t X t TOP: X t X t Nursing Process: Planning Xt Xt




2. Which of the following best N drXt e s C‘ prM
e x plRa i n sIt heGn u Br s .
drXt dXtrXt imary use of the nursing process when
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providing care to client USNT OXt Xt Xt t
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s
?
a. To explain nursing interventions to other health care professionals
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b. As a problem-solving tool to identify and treat clients‘ health care needs
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c. As a scientific-based process of diagnosing the client‘s health care problems
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d. To establish nursing theory that incorporates the biopsychosocial nature of humans
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ANS: B
The nursing process is an assertive problem-
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solving approach to the identification and treatment of clients‘ problems. Diagnosis is only
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on e phase of the nursing process. The
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primary use of the nursing process is in client care, not to establish nursing theory or explain n
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ursing interventions to other health care professionals.
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DIF: Cognitive Level: Comprehension Xt Xt TOP: Nursing Process: Implementation Xt Xt




3. The nurse is caring for a critically ill client in the intensive care unit and plans an every 2-
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hour turning schedule to prevent skin breakdown. Which type of nursing function is demo
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nst rated with this turning schedule?
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a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: D




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When implementing collaborative nursing actions, the nurse is responsible primarily for mo
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n itoring for complications of acute illness or providing care to prevent or treat complicatio
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ns. Independent nursing actions are focused on health promotion, illness prevention, and cli
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ent a dvocacy. A dependent action would require a physician order to implement. Cooperat
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ive nur sing functions are not described as one of the formal nursing functions.
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DIF: Cognitive Level: Application Xt Xt TOP: Nursing Process: Implementation Xt Xt




4. The nurse is caring for a client who has been admitted to the hospital for surgery and tells
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th e nurse, ―I do not feel right about leaving my children with my neighbour.‖ Which act
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ion sh ould the nurse take next?
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a. Reassure the client that these feelings are common for parents.
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b. Have the client call the children to ensure that they are doing well.
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c. Call the neighbour to determine whether adequate childcare is being provided.
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d. Gather more data about the client‘s feelings about the childcare arrangements.
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ANS: D
Since a complete assessment is necessary in order to identify a problem and choose an app
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ro priate intervention, the nurse‘s first action should be to obtain more information. The oth
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er ac tions may be appropriate, but more assessment is needed before the best intervention
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can be c hosen. Xt Xt Xt




DIF: Cognitive Level: Application Xt Xt TOP: Nursing Process: Assessment Xt Xt




5. The nurse is caring for a client who has left-
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sided paralysis as the result of a stroke and assesses a pressure injury on t he c l i e n t ‘ s
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N R
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l ef t h i p . W h ich of the following is the most
B.C M
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appropriate nursing diagnosis fUo r t Sh i s cNl i e nTt ? O
t
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X X t
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a. Impaired physical mobility related to decrease in muscle control (left-
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sided paralysis) Xt


b. Risk for impaired tissue integrity as evidenced by insufficient knowledge abo
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ut protecting tissue integrity
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c. Impaired skin integrity related to pressure over bony prominence (impaire
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d circulation) Xt


d. Ineffective tissue perfusion related to sedentary lifestyle Xt Xt Xt Xt Xt Xt




ANS: C
The client‘s major problem is the impaired skin integrity as demonstrated by the presence o
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f a pressure injury. The nurse is able to treat the cause of altered circulation and pressure b
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y fre quently repositioning the client. Although left-
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sided weakness is a problem for the client,
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the nurse cannot treat the weakness. The ―risk for‖ diagnosis is not appropriate for this clie
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nt, who already has impaired tissue integrity. The client does have ineffective tissue perfusi
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on, b ut the impaired skin integrity diagnosis indicates more clearly what the health proble
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m is. dXt




DIF: X t X t Cognitive Level: Application Xt Xt TOP: X t X t Nursing Process: Diagnosis Xt Xt




6. The nurse caring for a client with an infection has a nursing diagnosis of deficient fl
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ui d volume related to excessive diaphoresis. Which of the following is an appropriat
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e clie nt outcome?
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a. Client has a balanced intake and output. Xt Xt Xt Xt Xt Xt


b. Client‘s bedding is changed when it becomes damp. Xt Xt Xt Xt Xt Xt Xt




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, Medical-

c. Client understands the need for increased fluid intake.
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d. Client‘s skin remains cool and dry throughout hospitalization.
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ANS: A
This statement gives measurable data showing resolution of the problem of deficient fluid v
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ol ume that was identified in the nursing diagnosis statement. The other statements would n
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ot in dicate that the problem of deficient fluid volume was resolved.
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DIF: Cognitive Level: Application Xt Xt TOP: Nursing Process: Planning Xt Xt




7. Which of the following represents a nursing activity that is carried out during the evalua
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tio n phase of the nursing process?
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a. Determining if interventions have been effective in meeting client outcomes
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b. Documenting the nursing care plan in the progress notes in the medical record Xt Xt Xt Xt Xt Xt Xt Xt Xt Xt Xt Xt


c. Deciding whether the client‘s health problems have been completely resolved
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d. Asking the client to evaluate whether the nursing care provided was satisfactory
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ANS: A
Evaluation consists of determining whether the desired client outcomes have been met and
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w hether the nursing interventions were appropriate. The other responses do not describe th
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e eva luation phase.
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DIF: Cognitive Level: Comprehension Xt Xt TOP: Nursing Process: Evaluation Xt Xt




8. Which of the following would the nurse perform during the assessment phase of the nursi
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ng process?
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a. Obtains data with which to diagnose client problems
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b. Uses client data to develoNp p R
UrSi oNrTIi t y nGursB
dr in.
gCdiagMnoses
c. Teaches interventions to relieve client health problems
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d. Assists the client to identify realistic outcomes to health problems
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ANS: A
During the assessment phase, the nurse gathers information about the client. The other resp
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on ses are examples of the intervention, diagnosis, and planning phases of the nursing proc
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ess.

DIF: Cognitive Level: Knowledge Xt Xt TOP: Nursing Process: Assessment Xt Xt




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
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b. Risk for impaired tissue integrity related to sacral redness
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c. Ineffective coping related to insufficient sense of control. Xt Xt Xt Xt Xt Xt Xt


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 describ
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es a client‘s response to a health problem that can be treated by nursing. The use of a medi
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cal diagnosis (as in the responses beginning ―Altered tissue perfusion‖ and ―Altered urina
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ry elimination‖) is not appropriate. The response beginning ―Risk for impaired tissue integrit
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y‖ u ses the defining characteristics as the etiology.
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DIF: Cognitive Level: Comprehension Xt Xt TOP: Nursing Process: Diagnosis Xt Xt




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