TEST BANK
Medical-Surgical Nursing: Focus on Clinical Judgment
Linda F. Honan
3rd Edition
,Table of Contents
Chapter 01 The Nurse's Role in Adult Health Nursing 1
Chapter 02 Chronic Illness and End-of-Life Care 12
Chapter 03 Fluid and Electrolyte and Acid--Base Imbalances 24
Chapter 04 Perioperative Nursing 37
Chapter 05 Cancer Care 49
Chapter 06 Pain Management 61
Chapter 07 Nursing Assessment: Respiratory Function 74
Chapter 08 Nursing Management: Patients With Upper Respiratory Tract Disorders 85
Chapter 09 Nursing Management: Patients With Chest and Lower Respiratory Tract
Disorders 96
Chapter 10 Nursing Management of Patients Diagnosed With Chronic Obstructive
Pulmonary Disease and Asthma 107
Chapter 11 Nursing Assessment: Cardiovascular and Circulatory Function 118
Chapter 12 Nursing Management: Patients With Hypertension 128
Chapter 13 Nursing Management: Patients With Coronary Vascular Disorders 139
Chapter 14 Nursing Management: Patients With Complications From Heart Disease 150
Chapter 15 Nursing Management: Patients With Structural, Infectious, and Inflammatory
Cardiac Disorders 161
Chapter 16 Nursing Management: Patients With Arrhythmias and Conduction Problems 173
Chapter 17 Nursing Management: Patients With Vascular Disorders and Problems of
Peripheral Circulation 184
Chapter 18 Nursing Assessment: Hematologic Function 196
Chapter 19 Nursing Management: Patients With Hematologic Disorders 206
Chapter 20 Nursing Assessment: Digestive, Gastrointestinal, and Metabolic Function 217
Chapter 21 Nursing Management: Patients With Oral and Esophageal Disorders and
Patients Receiving Gastrointestinal Intubation, Enteral, and Parenteral Nutrition 229
Chapter 22 Nursing Management: Patients With Gastric and Duodenal Disorders 241
Chapter 23 Nursing Management: Patients With Intestinal and Rectal Disorders 252
Chapter 24 Nursing Management: Patients With Hepatic and Biliary Disorders 263
Chapter 25 Nursing Assessment: Renal and Urinary Tract Function 274
Chapter 26 Nursing Management: Patients With Renal Disorders 286
Chapter 27 Nursing Management: Patients With Urinary Disorders 298
Chapter 28 Nursing Assessment: Endocrine Function 310
Chapter 29 Nursing Management: Diabetes Mellitus 321
Chapter 30 Nursing Management: Patients With Endocrine Disorders 333
Chapter 31 Nursing Assessment: Assigned Female at Birth (AFAB) and Assigned Male at
Birth (AMAB) Reproductive Function 344
Chapter 32 Nursing Management: Patients With Breast and Female Reproductive
Disorders 355
,Chapter 33 Care of the Assigned Male at Birth (AMAB) Patient With Reproductive
Disorders 367
Chapter 34 Nursing Management: Patients With Sexually Transmitted Infections 379
Chapter 35 Nursing Assessment: Immune Function 390
Chapter 36 Nursing Management: Patients With Immunodeficiency, HIV Infection, and
AIDS 401
Chapter 37 Nursing Management: Patients With Allergic Disorders 412
Chapter 38 Nursing Management: Patients With Rheumatic Disorders 423
Chapter 39 Nursing Assessment: Musculoskeletal Function 434
Chapter 40 Nursing Management: Patients With Musculoskeletal Disorders 444
Chapter 41 Nursing Management: Patients With Musculoskeletal Trauma 455
Chapter 42 Nursing Assessment: Neurologic Function 466
Chapter 43 Nursing Management: Patients With Oncologic Disorders of the Brain and
Spinal Cord 477
Chapter 44 Nursing Management: Patients With Neurologic Trauma 488
Chapter 45 Nursing Management: Patients With Neurologic Disorders 499
Chapter 46 Nursing Management: Patients With Cerebrovascular Disorders 510
Chapter 47 Nursing Assessment: Sensorineural Function 522
Chapter 48 Nursing Management: Patients With Eye and Vision Disorders 533
Chapter 49 Nursing Management: Patients With Hearing and Balance Disorders 544
Chapter 50 Nursing Assessment: Integumentary Function 555
Chapter 51 Nursing Management: Patients With Dermatologic Problems 566
Chapter 52 Nursing Management: Patients With Burn Injury 577
Chapter 53 Nursing Management: Shock and Multisystem Failure 589
Chapter 54 Nursing Management: Critical Care 601
Chapter 55 Nursing Management: Emergencies and Disasters 612
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Test Bank - Medical-Surgical Nursing: Focus on Clinical Judgment, 3rd Edition (Honan, 2024)
Chapter 1, The Nurse's Role in Adult Health Nursing
1. The public health nurse is presenting a health promotion class to a group of new parents.
How should the nurse best define health?
A. The absence of disease or stabilization of existing diseases
B. A state of having fulfillment in all domains of life
C. Individual and societal well-being
D. Physical, mental, and social well-being
ANS: D
Rationale: The World Health Organization (WHO) defines health in the preamble to its
constitution as a “state of complete physical, mental, and social well-being and not merely
the absence of disease and infirmity.” Health and illness are experienced on a continuum by
each individual. The concept of wellness includes the additional consideration of societal
well-being. Wellness has been thought of as being equivalent to health but is more
comprehensive and interrelational and includes various aspects of life that lead to health:
emotional, environmental, financial, intellectual, occupational, physical, social, and
spiritual. Fulfillment is consistent with health, but the concepts are not synonymous.
PTS: 1 REF: Page and Header: 6, Health, Wellness, and Health Promotion
OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter: 1 KEY: Integrated Process: Teaching/Learning
BLM: Cognitive Level: Apply NOT: Multiple Choice
2. A nurse is speaking to a group of prospective nursing students about what it is like to be a
nurse. Which of the following characteristics would the nurse cite as necessary to possess to
be an effective nurse?
A. Sensitivity to cultural differences
B. Ability to problem-solve independently
C. Strict adherence to routine
D. Ability to handle criticism without being affected by it
ANS: A
Rationale: To promote an effective nurse–client relationship and positive outcomes of care,
nursing care must be culturally competent, appropriate, and sensitive to cultural differences.
Problem-solving in nursing often requires collaboration. Nursing requires adaptability as
well as adherence to routine and processes. The ability to handle criticism is important, but
it is unrealistic to expect to be unaffected by it.
PTS: 1 REF: Page and Header: 7, Immigration and Diversity
OBJ: 5 NAT: Client Needs: Psychosocial Integrity
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
3. The nurse is asked to speak to members of a self-care education program. Which topic(s)
will the nurse address that best promote self-care? Select all that apply.
A. Disease prevention
B. Government advocacy and lobbying
C. Judicious use of online communities
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Test Bank - Medical-Surgical Nursing: Focus on Clinical Judgment, 3rd Edition (Honan, 2024)
D. Management of illness
E. Adequate prenatal care
ANS: A, D
Rationale: Organized self-care education programs emphasize health promotion, disease
prevention, management of illness, and judicious use of the professional health care system.
Prenatal care, lobbying, and Internet activities are secondary.
PTS: 1 REF: Page and Header: 6, Health, Wellness, and Health Promotion
OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Understand NOT: Multiple Select
4. The home health nurse is assisting a client and their family in planning the client’s return to
work after surgery and preventing postsurgical complications. The nurse is preparing a plan
of care that addresses the client’s multifaceted needs. To which level of Maslow hierarchy
of basic needs does the client’s need for self-fulfillment relate?
A. Physiologic
B. Transcendence
C. Love and belonging
D. Self-actualization
ANS: D
Rationale: Maslow’s highest level of human needs is self-actualization, which includes
self-fulfillment, desire to know and understand, and aesthetic needs. Self-fulfillment does
not relate directly to love, transcendence, or physiology.
PTS: 1 REF: Page and Header: 6, The Patient OBJ: 3
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Understand NOT: Multiple Choice
5. The nurse is planning the care of several clients at the community clinic, with the view that
health and illness are not static states but rather exist on a continuum. What statements align
with this view? Select all that apply.
A. Care should focus primarily on the treatment of disease.
B. A person's state of health is ever changing.
C. A person’s transitions from health to illness are often rapid.
D. Care should focus on the client's adherence with interventions.
E. A person simultaneously possesses degrees of both health and illness.
ANS: B, E
Rationale: By viewing health and illness on a continuum, it is possible to consider a person
as being neither completely healthy nor completely ill. Instead, a person's state of health is
ever changing and has the potential to range from high-level wellness to extremely poor
health and imminent death. Client care should not focus just on the treatment of disease. The
pace of change in a person’s state of health and adherence with treatment are not key to this
view of health.
PTS: 1 REF: Page and Header: 6, Health, Wellness, and Health Promotion
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2|Page
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Test Bank - Medical-Surgical Nursing: Focus on Clinical Judgment, 3rd Edition (Honan, 2024)
OBJ: 2
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Select
6. A nurse is leading a community health clinic. What should the nurse emphasize to promote
disease prevention?
A. It is best achieved through attending self-help groups.
B. It is best achieved by reducing psychological stress.
C. It is best achieved by being an active participant in the community.
D. It is best achieved by exhibiting behaviors that promote health.
ANS: D
Rationale: Today, increasing emphasis is placed on health, health promotion, wellness, and
self-care. Health is seen as resulting from a lifestyle oriented toward wellness. While
attending self-help groups, reducing stress, and being an active participant in the community
are all activities consistent with a healthy lifestyle, the primary method of disease prevention
is health-promoting behaviors.
PTS: 1 REF: Page and Header: 6, Health, Wellness, and Health Promotion
OBJ: 5 NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter: 1 KEY: Integrated Process: Teaching/Learning
BLM: Cognitive Level: Apply NOT: Multiple Choice
7. The nurse is introducing a quality improvement program related to reducing complications
after a stroke. Which universal characteristic(s) of quality improvement efforts will the
nurse incorporate into the introduction?
A. The program will establish consequences for health care professionals' actions.
B. The program will emphasize the need for evidence-based practice.
C. The program will identify specific incidents related to quality.
D. The program will seek to justify health care costs and systems.
E. The program will focus on addressing the need for safe delivery of services.
ANS: B, E
Rationale: Numerous models seek to improve the quality of health care delivery. A
commonality among them is a focus on the importance of evidence-based practice to
continuously improve the safety of the delivery system. Consequences, a focus on incidents,
and justification for health care costs are not universal characteristics of quality
improvement efforts.
PTS: 1 REF: Page and Header: 10, Box 1-5 QSEN Competencies
OBJ: 5
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Understand NOT: Multiple Select
8. The nurse is promoting positive health outcomes for clients after discharge from the acute
care facility. Which action(s) will the nurse prioritize? Select all that apply.
A. Promotion of health literacy during hospitalization
B. Close communication with primary providers
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Test Bank - Medical-Surgical Nursing: Focus on Clinical Judgment, 3rd Edition (Honan, 2024)
C. Thorough and evidence-based discharge planning
D. Participation in continuing education initiatives
E. Follow-up after discharge to ensure understanding of education
ANS: C, E
Rationale: Following discharges that occur after increasingly short hospital stays, nurses in
the community care for clients who need high-technology acute care services as well as
long-term care in the home. This is dependent on effective discharge planning and follow-up
care to a greater degree than continuing education, communication with health care
providers, or promotion of health literacy.
PTS: 1 REF: Page and Header: 21, Nursing Process: Patient Teaching
OBJ: 5
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Select
9. The nurse is admitting a client to the medical unit after they were transferred from the
emergency department. What is the nurse's priority action at this time?
A. Identifying the immediate needs of the client
B. Checking the admitting physician's prescriptions
C. Obtaining a baseline set of vital signs
D. Allowing the family to be with the client
ANS: A
Rationale: Among the nurse's important functions in health care delivery, identifying the
client's immediate needs and working in concert with the client to address them is most
important. The other nursing functions are important, but they are not the priority at this
time.
PTS: 1 REF: Page and Header: 5, The Patient OBJ: 2
NAT: Client Needs: Safe, Nursing Process Effective Care Environment: Management of
Care TOP: Chapter: 1 KEY: Integrated Process:
BLM: Cognitive Level: Apply NOT: Multiple Choice
10. A nurse practicing in an oncology clinic administers the prescribed antineoplastic drug.
Which type of nursing action is the nursing engaging in?
A. Interdependent
B. Dependent
C. Independent
D. Delegated
ANS: B
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Test Bank - Medical-Surgical Nursing: Focus on Clinical Judgment, 3rd Edition (Honan, 2024)
Rationale: Nurses need to know and understand their scope of practice, as well as those of
other professions with which they interact during patient care. Some actions are described as
dependent, meaning that a specific action depends upon an order from a medical doctor or
licensed independent practitioner; an example is administering medications that have been
ordered. Other actions are interdependent and are done in a collaborative manner with
others. Interdependent actions might include medication titration or participation in
interdisciplinary rounds. Independent actions can be performed by the registered nurse (RN)
without input from others. Independent actions include performing nursing assessments and
patient education. Delegation is a tool that nurses use and is defined as the process by which
a nurse assigns or directs another member of the health care staff to perform nursing
activities.
PTS: 1 REF: Page and Header: 3, General Professional Nursing
OBJ: 1
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
11. The nurse collaborates with other disciplines for clients rehabilitating from various illnesses.
Which is the best example of a collaborative practice model? Select all that apply.
A. The nurse and the primary care provider jointly making clinical decisions.
B. The nurse accompanying the primary care provider on rounds.
C. The nurse making a referral on behalf of the client.
D. The nurse attending an appointment with the client.
E. The nurse and dietitian addressing a client’s nutritional needs.
ANS: A, E
Rationale: The collaborative model, or a variation of it, promotes shared participation,
responsibility, and accountability in a health care environment that is striving to meet the
complex health care needs of the public and/or client. Collaborative practice goes beyond a
nurse simply accompanying a primary care provider. Making referrals and accompanying a
client do not demonstrate interprofessional collaboration because they are independent
nursing actions.
PTS: 1
REF: Page and Header: 3, Box 1-1 American Nurses Association Code of Ethics for
Nurses OBJ: 4 NAT: Client Needs: Nursing Process
TOP: Chapter: 1
KEY: Integrated Process: Safe, Effective Care Environment: Management of Care
BLM: Cognitive Level: Analyze NOT: Multiple Select
12. According to the Maslow hierarchy of needs, what dimension of care should the nurse
consider primary in importance when caring for a dying client?
A. Spiritual
B. Social
C. Physiologic
D. Emotional
ANS: C
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Test Bank - Medical-Surgical Nursing: Focus on Clinical Judgment, 3rd Edition (Honan, 2024)
Rationale: Maslow ranked human needs as follows: physiologic needs; safety and security;
sense of belonging and affection; esteem and self-respect; and self-actualization.
Lower-level needs always remain, and a person’s ability to pursue higher-level needs
generally indicates movement toward improved health and well-being. While the nurse
would focus on other needs as appropriate in a given situation, the primary nursing focus for
the dying client would be on physiologic needs and physical comfort.
PTS: 1 REF: Page and Header: 6, The Patient OBJ: 2
NAT: Client Needs: Psychosocial Integrity TOP: Chapter: 1
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Understand NOT: Multiple Choice
13. A nurse is planning a client's care with consideration of the Maslow hierarchy of needs.
Within this framework of understanding, which will the nurse prioritize first? Select all that
apply.
A. Allowing the family to see a newly admitted client
B. Ambulating the client in the hallway
C. Administering pain medication
D. Teaching a client to self-administer insulin safely
E. Feeding a client incapable of feeding themselves
ANS: C, E
Rationale: In the Maslow hierarchy of needs, pain relief addresses the client's basic
physiologic need, which is the first level the client must achieve before addressing higher
level needs. Activity, such as ambulation, is a higher-level need above the physiologic need.
Allowing the client to see family addresses a higher-level need related to love and
belonging. Teaching the client is also a higher-level need related to the desire to know and
understand and is not appropriate at this time, as the basic physiologic need of pain control
and nutrition must first be addressed.
PTS: 1 REF: Page and Header: 6, The Patient OBJ: 2
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Select
14. The nurse is preparing for practice after graduation. Which action will the nurse take when
exploring the legal basis for the scope of practice?
A. Consult the Nursing code of ethics.
B. Consult the institution’s code of nursing conduct.
C. Consult the nurse practice act in the nurse's jurisdiction.
D. Consult the client for their preferences.
ANS: C
Rationale: Nurses have a responsibility to comply with the nurse practice act of the
jurisdiction in which they practice. A nurse's scope of practice is not determined by codes of
ethics, codes of conduct, or client preferences.
PTS: 1 REF: Page and Header: 2, General Professional Nursing
OBJ: 1
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
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6|Page
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Test Bank - Medical-Surgical Nursing: Focus on Clinical Judgment, 3rd Edition (Honan, 2024)
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Understand NOT: Multiple Choice
15. The nurse is evaluating the role of a licensed independent practitioner. Which nurse is
considered a licensed independent practitioner?
A. A nurse manager
B. A nurse educator
C. A nurse clinician
D. A nurse practitioner
ANS: D
Rationale: The training and licensure of a nurse practitioner allows for independent medical
actions. While the nurse manager, educator, and clinician all have specialized skills, none
are legally able to order care for a client.
PTS: 1 REF: Page and Header: 3, General Professional Nursing
OBJ: 1
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Remember NOT: Multiple Choice
16. Professional nursing expands and grows because of factors driven by the changing needs of
health care consumers. Which of the following is a factor that nurses should consider in the
planning and provision of health care?
A. Decreased access to health care information by individuals
B. Gradual increases in the cultural unity of the population
C. Increasing mean and median age of the population
D. Decreasing consumer expectations related to health care outcomes
ANS: C
Rationale: The decline in birth rate and the increase in lifespan have resulted in an older
population. The population has become more culturally diverse, not homogenous, in recent
decades. Access to information and consumer expectations continue to increase.
PTS: 1 REF: Page and Header: 9, The Older Population
OBJ: 5
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Analyze NOT: Multiple Choice
17. A public health nurse is requested to initiate a health promotion program that meets the
health care needs of older adults in the community. Which factor is most likely to influence
the nurse's choice of interventions? Select all that apply.
A. Management of chronic conditions and disability
B. Management of conditions affecting an increasingly younger population
C. A shifting focus to disease management
D. An increasing focus on acute conditions
E. A focus on achieving an optimal level of health
ANS: A, E
______________________________________________________________________________________________
7|Page
Medical-Surgical Nursing: Focus on Clinical Judgment
Linda F. Honan
3rd Edition
,Table of Contents
Chapter 01 The Nurse's Role in Adult Health Nursing 1
Chapter 02 Chronic Illness and End-of-Life Care 12
Chapter 03 Fluid and Electrolyte and Acid--Base Imbalances 24
Chapter 04 Perioperative Nursing 37
Chapter 05 Cancer Care 49
Chapter 06 Pain Management 61
Chapter 07 Nursing Assessment: Respiratory Function 74
Chapter 08 Nursing Management: Patients With Upper Respiratory Tract Disorders 85
Chapter 09 Nursing Management: Patients With Chest and Lower Respiratory Tract
Disorders 96
Chapter 10 Nursing Management of Patients Diagnosed With Chronic Obstructive
Pulmonary Disease and Asthma 107
Chapter 11 Nursing Assessment: Cardiovascular and Circulatory Function 118
Chapter 12 Nursing Management: Patients With Hypertension 128
Chapter 13 Nursing Management: Patients With Coronary Vascular Disorders 139
Chapter 14 Nursing Management: Patients With Complications From Heart Disease 150
Chapter 15 Nursing Management: Patients With Structural, Infectious, and Inflammatory
Cardiac Disorders 161
Chapter 16 Nursing Management: Patients With Arrhythmias and Conduction Problems 173
Chapter 17 Nursing Management: Patients With Vascular Disorders and Problems of
Peripheral Circulation 184
Chapter 18 Nursing Assessment: Hematologic Function 196
Chapter 19 Nursing Management: Patients With Hematologic Disorders 206
Chapter 20 Nursing Assessment: Digestive, Gastrointestinal, and Metabolic Function 217
Chapter 21 Nursing Management: Patients With Oral and Esophageal Disorders and
Patients Receiving Gastrointestinal Intubation, Enteral, and Parenteral Nutrition 229
Chapter 22 Nursing Management: Patients With Gastric and Duodenal Disorders 241
Chapter 23 Nursing Management: Patients With Intestinal and Rectal Disorders 252
Chapter 24 Nursing Management: Patients With Hepatic and Biliary Disorders 263
Chapter 25 Nursing Assessment: Renal and Urinary Tract Function 274
Chapter 26 Nursing Management: Patients With Renal Disorders 286
Chapter 27 Nursing Management: Patients With Urinary Disorders 298
Chapter 28 Nursing Assessment: Endocrine Function 310
Chapter 29 Nursing Management: Diabetes Mellitus 321
Chapter 30 Nursing Management: Patients With Endocrine Disorders 333
Chapter 31 Nursing Assessment: Assigned Female at Birth (AFAB) and Assigned Male at
Birth (AMAB) Reproductive Function 344
Chapter 32 Nursing Management: Patients With Breast and Female Reproductive
Disorders 355
,Chapter 33 Care of the Assigned Male at Birth (AMAB) Patient With Reproductive
Disorders 367
Chapter 34 Nursing Management: Patients With Sexually Transmitted Infections 379
Chapter 35 Nursing Assessment: Immune Function 390
Chapter 36 Nursing Management: Patients With Immunodeficiency, HIV Infection, and
AIDS 401
Chapter 37 Nursing Management: Patients With Allergic Disorders 412
Chapter 38 Nursing Management: Patients With Rheumatic Disorders 423
Chapter 39 Nursing Assessment: Musculoskeletal Function 434
Chapter 40 Nursing Management: Patients With Musculoskeletal Disorders 444
Chapter 41 Nursing Management: Patients With Musculoskeletal Trauma 455
Chapter 42 Nursing Assessment: Neurologic Function 466
Chapter 43 Nursing Management: Patients With Oncologic Disorders of the Brain and
Spinal Cord 477
Chapter 44 Nursing Management: Patients With Neurologic Trauma 488
Chapter 45 Nursing Management: Patients With Neurologic Disorders 499
Chapter 46 Nursing Management: Patients With Cerebrovascular Disorders 510
Chapter 47 Nursing Assessment: Sensorineural Function 522
Chapter 48 Nursing Management: Patients With Eye and Vision Disorders 533
Chapter 49 Nursing Management: Patients With Hearing and Balance Disorders 544
Chapter 50 Nursing Assessment: Integumentary Function 555
Chapter 51 Nursing Management: Patients With Dermatologic Problems 566
Chapter 52 Nursing Management: Patients With Burn Injury 577
Chapter 53 Nursing Management: Shock and Multisystem Failure 589
Chapter 54 Nursing Management: Critical Care 601
Chapter 55 Nursing Management: Emergencies and Disasters 612
,______________________________________________________________________________________________
Test Bank - Medical-Surgical Nursing: Focus on Clinical Judgment, 3rd Edition (Honan, 2024)
Chapter 1, The Nurse's Role in Adult Health Nursing
1. The public health nurse is presenting a health promotion class to a group of new parents.
How should the nurse best define health?
A. The absence of disease or stabilization of existing diseases
B. A state of having fulfillment in all domains of life
C. Individual and societal well-being
D. Physical, mental, and social well-being
ANS: D
Rationale: The World Health Organization (WHO) defines health in the preamble to its
constitution as a “state of complete physical, mental, and social well-being and not merely
the absence of disease and infirmity.” Health and illness are experienced on a continuum by
each individual. The concept of wellness includes the additional consideration of societal
well-being. Wellness has been thought of as being equivalent to health but is more
comprehensive and interrelational and includes various aspects of life that lead to health:
emotional, environmental, financial, intellectual, occupational, physical, social, and
spiritual. Fulfillment is consistent with health, but the concepts are not synonymous.
PTS: 1 REF: Page and Header: 6, Health, Wellness, and Health Promotion
OBJ: 3 NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter: 1 KEY: Integrated Process: Teaching/Learning
BLM: Cognitive Level: Apply NOT: Multiple Choice
2. A nurse is speaking to a group of prospective nursing students about what it is like to be a
nurse. Which of the following characteristics would the nurse cite as necessary to possess to
be an effective nurse?
A. Sensitivity to cultural differences
B. Ability to problem-solve independently
C. Strict adherence to routine
D. Ability to handle criticism without being affected by it
ANS: A
Rationale: To promote an effective nurse–client relationship and positive outcomes of care,
nursing care must be culturally competent, appropriate, and sensitive to cultural differences.
Problem-solving in nursing often requires collaboration. Nursing requires adaptability as
well as adherence to routine and processes. The ability to handle criticism is important, but
it is unrealistic to expect to be unaffected by it.
PTS: 1 REF: Page and Header: 7, Immigration and Diversity
OBJ: 5 NAT: Client Needs: Psychosocial Integrity
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
3. The nurse is asked to speak to members of a self-care education program. Which topic(s)
will the nurse address that best promote self-care? Select all that apply.
A. Disease prevention
B. Government advocacy and lobbying
C. Judicious use of online communities
______________________________________________________________________________________________
1|Page
,______________________________________________________________________________________________
Test Bank - Medical-Surgical Nursing: Focus on Clinical Judgment, 3rd Edition (Honan, 2024)
D. Management of illness
E. Adequate prenatal care
ANS: A, D
Rationale: Organized self-care education programs emphasize health promotion, disease
prevention, management of illness, and judicious use of the professional health care system.
Prenatal care, lobbying, and Internet activities are secondary.
PTS: 1 REF: Page and Header: 6, Health, Wellness, and Health Promotion
OBJ: 2 NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Understand NOT: Multiple Select
4. The home health nurse is assisting a client and their family in planning the client’s return to
work after surgery and preventing postsurgical complications. The nurse is preparing a plan
of care that addresses the client’s multifaceted needs. To which level of Maslow hierarchy
of basic needs does the client’s need for self-fulfillment relate?
A. Physiologic
B. Transcendence
C. Love and belonging
D. Self-actualization
ANS: D
Rationale: Maslow’s highest level of human needs is self-actualization, which includes
self-fulfillment, desire to know and understand, and aesthetic needs. Self-fulfillment does
not relate directly to love, transcendence, or physiology.
PTS: 1 REF: Page and Header: 6, The Patient OBJ: 3
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Understand NOT: Multiple Choice
5. The nurse is planning the care of several clients at the community clinic, with the view that
health and illness are not static states but rather exist on a continuum. What statements align
with this view? Select all that apply.
A. Care should focus primarily on the treatment of disease.
B. A person's state of health is ever changing.
C. A person’s transitions from health to illness are often rapid.
D. Care should focus on the client's adherence with interventions.
E. A person simultaneously possesses degrees of both health and illness.
ANS: B, E
Rationale: By viewing health and illness on a continuum, it is possible to consider a person
as being neither completely healthy nor completely ill. Instead, a person's state of health is
ever changing and has the potential to range from high-level wellness to extremely poor
health and imminent death. Client care should not focus just on the treatment of disease. The
pace of change in a person’s state of health and adherence with treatment are not key to this
view of health.
PTS: 1 REF: Page and Header: 6, Health, Wellness, and Health Promotion
______________________________________________________________________________________________
2|Page
,______________________________________________________________________________________________
Test Bank - Medical-Surgical Nursing: Focus on Clinical Judgment, 3rd Edition (Honan, 2024)
OBJ: 2
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Select
6. A nurse is leading a community health clinic. What should the nurse emphasize to promote
disease prevention?
A. It is best achieved through attending self-help groups.
B. It is best achieved by reducing psychological stress.
C. It is best achieved by being an active participant in the community.
D. It is best achieved by exhibiting behaviors that promote health.
ANS: D
Rationale: Today, increasing emphasis is placed on health, health promotion, wellness, and
self-care. Health is seen as resulting from a lifestyle oriented toward wellness. While
attending self-help groups, reducing stress, and being an active participant in the community
are all activities consistent with a healthy lifestyle, the primary method of disease prevention
is health-promoting behaviors.
PTS: 1 REF: Page and Header: 6, Health, Wellness, and Health Promotion
OBJ: 5 NAT: Client Needs: Health Promotion and Maintenance
TOP: Chapter: 1 KEY: Integrated Process: Teaching/Learning
BLM: Cognitive Level: Apply NOT: Multiple Choice
7. The nurse is introducing a quality improvement program related to reducing complications
after a stroke. Which universal characteristic(s) of quality improvement efforts will the
nurse incorporate into the introduction?
A. The program will establish consequences for health care professionals' actions.
B. The program will emphasize the need for evidence-based practice.
C. The program will identify specific incidents related to quality.
D. The program will seek to justify health care costs and systems.
E. The program will focus on addressing the need for safe delivery of services.
ANS: B, E
Rationale: Numerous models seek to improve the quality of health care delivery. A
commonality among them is a focus on the importance of evidence-based practice to
continuously improve the safety of the delivery system. Consequences, a focus on incidents,
and justification for health care costs are not universal characteristics of quality
improvement efforts.
PTS: 1 REF: Page and Header: 10, Box 1-5 QSEN Competencies
OBJ: 5
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Understand NOT: Multiple Select
8. The nurse is promoting positive health outcomes for clients after discharge from the acute
care facility. Which action(s) will the nurse prioritize? Select all that apply.
A. Promotion of health literacy during hospitalization
B. Close communication with primary providers
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Test Bank - Medical-Surgical Nursing: Focus on Clinical Judgment, 3rd Edition (Honan, 2024)
C. Thorough and evidence-based discharge planning
D. Participation in continuing education initiatives
E. Follow-up after discharge to ensure understanding of education
ANS: C, E
Rationale: Following discharges that occur after increasingly short hospital stays, nurses in
the community care for clients who need high-technology acute care services as well as
long-term care in the home. This is dependent on effective discharge planning and follow-up
care to a greater degree than continuing education, communication with health care
providers, or promotion of health literacy.
PTS: 1 REF: Page and Header: 21, Nursing Process: Patient Teaching
OBJ: 5
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Select
9. The nurse is admitting a client to the medical unit after they were transferred from the
emergency department. What is the nurse's priority action at this time?
A. Identifying the immediate needs of the client
B. Checking the admitting physician's prescriptions
C. Obtaining a baseline set of vital signs
D. Allowing the family to be with the client
ANS: A
Rationale: Among the nurse's important functions in health care delivery, identifying the
client's immediate needs and working in concert with the client to address them is most
important. The other nursing functions are important, but they are not the priority at this
time.
PTS: 1 REF: Page and Header: 5, The Patient OBJ: 2
NAT: Client Needs: Safe, Nursing Process Effective Care Environment: Management of
Care TOP: Chapter: 1 KEY: Integrated Process:
BLM: Cognitive Level: Apply NOT: Multiple Choice
10. A nurse practicing in an oncology clinic administers the prescribed antineoplastic drug.
Which type of nursing action is the nursing engaging in?
A. Interdependent
B. Dependent
C. Independent
D. Delegated
ANS: B
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Test Bank - Medical-Surgical Nursing: Focus on Clinical Judgment, 3rd Edition (Honan, 2024)
Rationale: Nurses need to know and understand their scope of practice, as well as those of
other professions with which they interact during patient care. Some actions are described as
dependent, meaning that a specific action depends upon an order from a medical doctor or
licensed independent practitioner; an example is administering medications that have been
ordered. Other actions are interdependent and are done in a collaborative manner with
others. Interdependent actions might include medication titration or participation in
interdisciplinary rounds. Independent actions can be performed by the registered nurse (RN)
without input from others. Independent actions include performing nursing assessments and
patient education. Delegation is a tool that nurses use and is defined as the process by which
a nurse assigns or directs another member of the health care staff to perform nursing
activities.
PTS: 1 REF: Page and Header: 3, General Professional Nursing
OBJ: 1
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Choice
11. The nurse collaborates with other disciplines for clients rehabilitating from various illnesses.
Which is the best example of a collaborative practice model? Select all that apply.
A. The nurse and the primary care provider jointly making clinical decisions.
B. The nurse accompanying the primary care provider on rounds.
C. The nurse making a referral on behalf of the client.
D. The nurse attending an appointment with the client.
E. The nurse and dietitian addressing a client’s nutritional needs.
ANS: A, E
Rationale: The collaborative model, or a variation of it, promotes shared participation,
responsibility, and accountability in a health care environment that is striving to meet the
complex health care needs of the public and/or client. Collaborative practice goes beyond a
nurse simply accompanying a primary care provider. Making referrals and accompanying a
client do not demonstrate interprofessional collaboration because they are independent
nursing actions.
PTS: 1
REF: Page and Header: 3, Box 1-1 American Nurses Association Code of Ethics for
Nurses OBJ: 4 NAT: Client Needs: Nursing Process
TOP: Chapter: 1
KEY: Integrated Process: Safe, Effective Care Environment: Management of Care
BLM: Cognitive Level: Analyze NOT: Multiple Select
12. According to the Maslow hierarchy of needs, what dimension of care should the nurse
consider primary in importance when caring for a dying client?
A. Spiritual
B. Social
C. Physiologic
D. Emotional
ANS: C
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Test Bank - Medical-Surgical Nursing: Focus on Clinical Judgment, 3rd Edition (Honan, 2024)
Rationale: Maslow ranked human needs as follows: physiologic needs; safety and security;
sense of belonging and affection; esteem and self-respect; and self-actualization.
Lower-level needs always remain, and a person’s ability to pursue higher-level needs
generally indicates movement toward improved health and well-being. While the nurse
would focus on other needs as appropriate in a given situation, the primary nursing focus for
the dying client would be on physiologic needs and physical comfort.
PTS: 1 REF: Page and Header: 6, The Patient OBJ: 2
NAT: Client Needs: Psychosocial Integrity TOP: Chapter: 1
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Understand NOT: Multiple Choice
13. A nurse is planning a client's care with consideration of the Maslow hierarchy of needs.
Within this framework of understanding, which will the nurse prioritize first? Select all that
apply.
A. Allowing the family to see a newly admitted client
B. Ambulating the client in the hallway
C. Administering pain medication
D. Teaching a client to self-administer insulin safely
E. Feeding a client incapable of feeding themselves
ANS: C, E
Rationale: In the Maslow hierarchy of needs, pain relief addresses the client's basic
physiologic need, which is the first level the client must achieve before addressing higher
level needs. Activity, such as ambulation, is a higher-level need above the physiologic need.
Allowing the client to see family addresses a higher-level need related to love and
belonging. Teaching the client is also a higher-level need related to the desire to know and
understand and is not appropriate at this time, as the basic physiologic need of pain control
and nutrition must first be addressed.
PTS: 1 REF: Page and Header: 6, The Patient OBJ: 2
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Apply NOT: Multiple Select
14. The nurse is preparing for practice after graduation. Which action will the nurse take when
exploring the legal basis for the scope of practice?
A. Consult the Nursing code of ethics.
B. Consult the institution’s code of nursing conduct.
C. Consult the nurse practice act in the nurse's jurisdiction.
D. Consult the client for their preferences.
ANS: C
Rationale: Nurses have a responsibility to comply with the nurse practice act of the
jurisdiction in which they practice. A nurse's scope of practice is not determined by codes of
ethics, codes of conduct, or client preferences.
PTS: 1 REF: Page and Header: 2, General Professional Nursing
OBJ: 1
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
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Test Bank - Medical-Surgical Nursing: Focus on Clinical Judgment, 3rd Edition (Honan, 2024)
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Understand NOT: Multiple Choice
15. The nurse is evaluating the role of a licensed independent practitioner. Which nurse is
considered a licensed independent practitioner?
A. A nurse manager
B. A nurse educator
C. A nurse clinician
D. A nurse practitioner
ANS: D
Rationale: The training and licensure of a nurse practitioner allows for independent medical
actions. While the nurse manager, educator, and clinician all have specialized skills, none
are legally able to order care for a client.
PTS: 1 REF: Page and Header: 3, General Professional Nursing
OBJ: 1
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Remember NOT: Multiple Choice
16. Professional nursing expands and grows because of factors driven by the changing needs of
health care consumers. Which of the following is a factor that nurses should consider in the
planning and provision of health care?
A. Decreased access to health care information by individuals
B. Gradual increases in the cultural unity of the population
C. Increasing mean and median age of the population
D. Decreasing consumer expectations related to health care outcomes
ANS: C
Rationale: The decline in birth rate and the increase in lifespan have resulted in an older
population. The population has become more culturally diverse, not homogenous, in recent
decades. Access to information and consumer expectations continue to increase.
PTS: 1 REF: Page and Header: 9, The Older Population
OBJ: 5
NAT: Client Needs: Safe, Effective Care Environment: Management of Care
TOP: Chapter: 1 KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Analyze NOT: Multiple Choice
17. A public health nurse is requested to initiate a health promotion program that meets the
health care needs of older adults in the community. Which factor is most likely to influence
the nurse's choice of interventions? Select all that apply.
A. Management of chronic conditions and disability
B. Management of conditions affecting an increasingly younger population
C. A shifting focus to disease management
D. An increasing focus on acute conditions
E. A focus on achieving an optimal level of health
ANS: A, E
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