Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
NURSINGTB.COM
, Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
Chapter 01: Introduction to Medical-
2p 2p 2p 2p
Surgical Nursing Practice in Canada Lewis: Medical-
2p 2p 2p 2p 2p 2p
Surgical Nursing in Canada, 5th Canadian Edition
2p 2p 2p 2p 2p 2p
MULTIPLE CHOICE 2p
1. When caring for clients using evidence-
2p 2p 2p 2p 2p
informed practice, which of the following does the nurse use?
2p 2p 2p 2p 2p 2p 2p 2p 2p
a. Clinical judgement based on experience 2p 2p 2p 2p
b. Evidence from a clinical research study 2p 2p 2p 2p 2p
c. The best available evidence to guide clinical expertise
2p 2p 2p 2p 2p 2p 2p
d. Evaluation of data showing that the client outcomes are met2p 2p 2p 2p 2p 2p 2p 2p 2p
ANS: 2 p C
Evidence-
informed nursing practice is a continuous interactive process involving the explicit, conscie
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ntious, and judicious consideration of the best available evidence to provide care. Four prim
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ary elements are: (a) clinical state, setting, and circumstances; (b) client preferences and ac
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
tions; (c) best research evidence; and (d) health care resources. Clinical judgement based on
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2
pthe nurse‘s clinical experience is part of EIP, but clinical decision making also should inco
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
rporate current research and research-
2p 2p 2p 2p
based guidelines. Evidence from one clinical research study does not provide an adequate s
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ubstantiation for interventions. Evaluation of client outcomes is important, but interventions
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
2pshould be based on research from randomized control studies with a large number of subj
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ects.
DIF: Cognitive Level: Comprehension 2p 2p TOP: 2 p Nursing Process: Planning 2p 2p
2. Which of the following best e x p l a i n s t h e n u r s e s ‘ primary use of the nursing process when
2p 2p 2p 2p 2p
N R I G B.C M 2p 2p 2p 2p 2p 2p 2p
providing care to clients 2p 2p 2p USNT O 2p 2p 2p
?
a. To explain nursing interventions to other health care professionals
2p 2p 2p 2p 2p 2p 2p 2p
b. As a problem-solving tool to identify and treat clients‘ health care needs
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
c. As a scientific-based process of diagnosing the client‘s health care problems
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
d. To establish nursing theory that incorporates the biopsychosocial nature of humans
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ANS: 2 p B
The nursing process is an assertive problem-solving approach to the identification and
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
treatment of clients‘ problems. Diagnosis is only one phase of the nursing process. The pri
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
mary use of the nursing process is in client care, not to establish nursing theory or explain n
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ursing interventions to other health care professionals.
2p 2p 2p 2p 2p 2p
DIF: Cognitive Level: Comprehension 2p 2p TOP: 2 p Nursing Process: Implementation 2p 2p
3. The nurse is caring for a critically ill client in the intensive care unit and plans an every 2-
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
hour turning schedule to prevent skin breakdown. Which type of nursing function is demon
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
strated with this turning schedule?
2p 2p 2p 2p
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: 2 p D
NURSINGTB.COM
, Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
When implementing collaborative nursing actions, the nurse is responsible primarily for mo
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
nitoring for complications of acute illness or providing care to prevent or treat complicatio
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ns. Independent nursing actions are focused on health promotion, illness prevention, and cli
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ent advocacy. A dependent action would require a physician order to implement. Cooperati
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ve nursing functions are not described as one of the formal nursing functions.
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
DIF: Cognitive Level: Application 2p 2p TOP: 2 p Nursing Process: Implementation 2p 2p
4. The nurse is caring for a client who has been admitted to the hospital for surgery and tells
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
the nurse, ―I do not feel right about leaving my children with my neighbour.‖ Which actio
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
n should the nurse take next?
2p 2p 2p 2p 2p
a. Reassure the client that these feelings are common for parents.
2p 2p 2p 2p 2p 2p 2p 2p 2p
b. Have the client call the children to ensure that they are doing well.
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
c. Call the neighbour to determine whether adequate childcare is being provided.
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
d. Gather more data about the client‘s feelings about the childcare arrangements.
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ANS: 2 p D
Since a complete assessment is necessary in order to identify a problem and choose an app
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ropriate intervention, the nurse‘s first action should be to obtain more information. The oth
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
er actions may be appropriate, but more assessment is needed before the best intervention c
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
an be chosen.
2p 2p
DIF: Cognitive Level: Application 2p 2p TOP: 2 p Nursing Process: Assessment 2p 2p
5. The nurse is caring for a client who has left-sided paralysis as the result of a stroke and
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
assesses a pressure injury o n the clie nt‘s left h ip . W hich of the following is the most
appropriate nursing diagnosisNfUoR hI Gl i e nT
Bt .
? OC M
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
r tS i s cN
2p 2p 2p 2p 2p
a. Impaired physical mobility related to decrease in muscle control (left-
2p 2p 2p 2p 2p 2p 2p 2p 2p
sided paralysis) 2p
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge abo
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ut protecting tissue integrity
2p 2p 2p
c. Impaired skin integrity related to pressure over bony prominence (impaire
2p 2p 2p 2p 2p 2p 2p 2p 2p
d circulation) 2p
d. Ineffective tissue perfusion related to sedentary lifestyle 2p 2p 2p 2p 2p 2p
ANS: 2 p C
The client‘s major problem is the impaired skin integrity as demonstrated by the presence of
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
a pressure injury. The nurse is able to treat the cause of altered circulation and pressure b
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
y frequently repositioning the client. Although left-
2p 2p 2p 2p 2p 2p
sided weakness is a problem for the client,
2p 2p 2p 2p 2p 2p 2p
the nurse cannot treat the weakness. The ―risk for‖ diagnosis is not appropriate for this clien
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
t, who already has impaired tissue integrity. The client does have ineffective tissue perfusio
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
n, but the impaired skin integrity diagnosis indicates more clearly what the health problem
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
is.
DIF: Cognitive Level: Application 2p 2p TOP: 2 p Nursing Process: Diagnosis 2p 2p
6. The nurse caring for a client with an infection has a nursing diagnosis of deficient fl
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
uid volume related to excessive diaphoresis. Which of the following is an appropriate
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
client outcome? 2p
a. Client has a balanced intake and output.2p 2p 2p 2p 2p 2p
b. Client‘s bedding is changed when it becomes damp. 2p 2p 2p 2p 2p 2p 2p
NURSINGTB.COM
, Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
c. Client understands the need for increased fluid intake.
2p 2p 2p 2p 2p 2p 2p
d. Client‘s skin remains cool and dry throughout hospitalization.
2p 2p 2p 2p 2p 2p 2p
ANS: 2 p A
This statement gives measurable data showing resolution of the problem of deficient fluid
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
volume that was identified in the nursing diagnosis statement. The other statements would n
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ot indicate that the problem of deficient fluid volume was resolved.
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
DIF: Cognitive Level: Application 2p 2p TOP: 2 p Nursing Process: Planning 2p 2p
7. Which of the following represents a nursing activity that is carried out during the evaluati
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
on phase of the nursing process?
2p 2p 2p 2p 2p
a. Determining if interventions have been effective in meeting client outcomes
2p 2p 2p 2p 2p 2p 2p 2p 2p
b. Documenting the nursing care plan in the progress notes in the medical record 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
c. Deciding whether the client‘s health problems have been completely resolved
2p 2p 2p 2p 2p 2p 2p 2p 2p
d. Asking the client to evaluate whether the nursing care provided was satisfactory
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ANS: 2 p A
Evaluation consists of determining whether the desired client outcomes have been met and
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
whether the nursing interventions were appropriate. The other responses do not describe the
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2
evaluation phase.
p 2p
DIF: Cognitive Level: Comprehension 2p 2p TOP: 2 p Nursing Process: Evaluation 2p 2p
8. Which of the following would the nurse perform during the assessment phase of the nursi
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ng process?
2p
a. Obtains data with which to diagnose client problems
2p 2p 2p 2p 2p 2p 2p
b. Uses client data to develoNp pR
2p
S NIty
Uriori T nGursBin.
gCdOiagMnoses
2p
c. Teaches interventions to relieve client health problems
2p
2p 2p
2p 2p
2p
2p 2p
2p
2p
2p
2p
2p
2p
d. Assists the client to identify realistic outcomes to health problems
2p 2p 2p 2p 2p 2p 2p 2p 2p
ANS: 2 p A
During the assessment phase, the nurse gathers information about the client. The other resp
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
onses are examples of the intervention, diagnosis, and planning phases of the nursing proces
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
s.
DIF: Cognitive Level: Knowledge 2p 2p TOP: 2 p Nursing Process: Assessment 2p 2p
9. Which of the following is an example of a correctly written nursing diagnosis statement?
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
a. Altered tissue perfusion related to heart failure
2p 2p 2p 2p 2p 2p
b. Risk for impaired tissue integrity related to sacral redness
2p 2p 2p 2p 2p 2p 2p 2p
c. Ineffective coping related to insufficient sense of control.
2p 2p 2p 2p 2p 2p 2p
d. Altered urinary elimination related to urinary tract infection
2p 2p 2p 2p 2p 2p 2p
ANS: 2 p C
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describ
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
es a client‘s response to a health problem that can be treated by nursing. The use of a med
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ical diagnosis (as in the responses beginning ―Altered tissue perfusion‖ and ―Altered urina
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ry
elimination‖) is not appropriate. The response beginning ―Risk for impaired tissue integrity‖
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
uses the defining characteristics as the etiology.
2p 2p 2p 2p 2p 2p
DIF: Cognitive Level: Comprehension 2p 2p TOP: 2 p Nursing Process: Diagnosis 2p 2p
NURSINGTB.COM
Surgical Nursing in Canada 5th Edition Lewi Test Bank
NURSINGTB.COM
, Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
Chapter 01: Introduction to Medical-
2p 2p 2p 2p
Surgical Nursing Practice in Canada Lewis: Medical-
2p 2p 2p 2p 2p 2p
Surgical Nursing in Canada, 5th Canadian Edition
2p 2p 2p 2p 2p 2p
MULTIPLE CHOICE 2p
1. When caring for clients using evidence-
2p 2p 2p 2p 2p
informed practice, which of the following does the nurse use?
2p 2p 2p 2p 2p 2p 2p 2p 2p
a. Clinical judgement based on experience 2p 2p 2p 2p
b. Evidence from a clinical research study 2p 2p 2p 2p 2p
c. The best available evidence to guide clinical expertise
2p 2p 2p 2p 2p 2p 2p
d. Evaluation of data showing that the client outcomes are met2p 2p 2p 2p 2p 2p 2p 2p 2p
ANS: 2 p C
Evidence-
informed nursing practice is a continuous interactive process involving the explicit, conscie
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ntious, and judicious consideration of the best available evidence to provide care. Four prim
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ary elements are: (a) clinical state, setting, and circumstances; (b) client preferences and ac
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
tions; (c) best research evidence; and (d) health care resources. Clinical judgement based on
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2
pthe nurse‘s clinical experience is part of EIP, but clinical decision making also should inco
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
rporate current research and research-
2p 2p 2p 2p
based guidelines. Evidence from one clinical research study does not provide an adequate s
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ubstantiation for interventions. Evaluation of client outcomes is important, but interventions
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
2pshould be based on research from randomized control studies with a large number of subj
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ects.
DIF: Cognitive Level: Comprehension 2p 2p TOP: 2 p Nursing Process: Planning 2p 2p
2. Which of the following best e x p l a i n s t h e n u r s e s ‘ primary use of the nursing process when
2p 2p 2p 2p 2p
N R I G B.C M 2p 2p 2p 2p 2p 2p 2p
providing care to clients 2p 2p 2p USNT O 2p 2p 2p
?
a. To explain nursing interventions to other health care professionals
2p 2p 2p 2p 2p 2p 2p 2p
b. As a problem-solving tool to identify and treat clients‘ health care needs
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
c. As a scientific-based process of diagnosing the client‘s health care problems
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
d. To establish nursing theory that incorporates the biopsychosocial nature of humans
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ANS: 2 p B
The nursing process is an assertive problem-solving approach to the identification and
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
treatment of clients‘ problems. Diagnosis is only one phase of the nursing process. The pri
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
mary use of the nursing process is in client care, not to establish nursing theory or explain n
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ursing interventions to other health care professionals.
2p 2p 2p 2p 2p 2p
DIF: Cognitive Level: Comprehension 2p 2p TOP: 2 p Nursing Process: Implementation 2p 2p
3. The nurse is caring for a critically ill client in the intensive care unit and plans an every 2-
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
hour turning schedule to prevent skin breakdown. Which type of nursing function is demon
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
strated with this turning schedule?
2p 2p 2p 2p
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: 2 p D
NURSINGTB.COM
, Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
When implementing collaborative nursing actions, the nurse is responsible primarily for mo
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
nitoring for complications of acute illness or providing care to prevent or treat complicatio
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ns. Independent nursing actions are focused on health promotion, illness prevention, and cli
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ent advocacy. A dependent action would require a physician order to implement. Cooperati
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ve nursing functions are not described as one of the formal nursing functions.
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
DIF: Cognitive Level: Application 2p 2p TOP: 2 p Nursing Process: Implementation 2p 2p
4. The nurse is caring for a client who has been admitted to the hospital for surgery and tells
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
the nurse, ―I do not feel right about leaving my children with my neighbour.‖ Which actio
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
n should the nurse take next?
2p 2p 2p 2p 2p
a. Reassure the client that these feelings are common for parents.
2p 2p 2p 2p 2p 2p 2p 2p 2p
b. Have the client call the children to ensure that they are doing well.
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
c. Call the neighbour to determine whether adequate childcare is being provided.
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
d. Gather more data about the client‘s feelings about the childcare arrangements.
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ANS: 2 p D
Since a complete assessment is necessary in order to identify a problem and choose an app
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ropriate intervention, the nurse‘s first action should be to obtain more information. The oth
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
er actions may be appropriate, but more assessment is needed before the best intervention c
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
an be chosen.
2p 2p
DIF: Cognitive Level: Application 2p 2p TOP: 2 p Nursing Process: Assessment 2p 2p
5. The nurse is caring for a client who has left-sided paralysis as the result of a stroke and
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
assesses a pressure injury o n the clie nt‘s left h ip . W hich of the following is the most
appropriate nursing diagnosisNfUoR hI Gl i e nT
Bt .
? OC M
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
r tS i s cN
2p 2p 2p 2p 2p
a. Impaired physical mobility related to decrease in muscle control (left-
2p 2p 2p 2p 2p 2p 2p 2p 2p
sided paralysis) 2p
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge abo
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ut protecting tissue integrity
2p 2p 2p
c. Impaired skin integrity related to pressure over bony prominence (impaire
2p 2p 2p 2p 2p 2p 2p 2p 2p
d circulation) 2p
d. Ineffective tissue perfusion related to sedentary lifestyle 2p 2p 2p 2p 2p 2p
ANS: 2 p C
The client‘s major problem is the impaired skin integrity as demonstrated by the presence of
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
a pressure injury. The nurse is able to treat the cause of altered circulation and pressure b
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
y frequently repositioning the client. Although left-
2p 2p 2p 2p 2p 2p
sided weakness is a problem for the client,
2p 2p 2p 2p 2p 2p 2p
the nurse cannot treat the weakness. The ―risk for‖ diagnosis is not appropriate for this clien
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
t, who already has impaired tissue integrity. The client does have ineffective tissue perfusio
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
n, but the impaired skin integrity diagnosis indicates more clearly what the health problem
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
is.
DIF: Cognitive Level: Application 2p 2p TOP: 2 p Nursing Process: Diagnosis 2p 2p
6. The nurse caring for a client with an infection has a nursing diagnosis of deficient fl
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
uid volume related to excessive diaphoresis. Which of the following is an appropriate
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
client outcome? 2p
a. Client has a balanced intake and output.2p 2p 2p 2p 2p 2p
b. Client‘s bedding is changed when it becomes damp. 2p 2p 2p 2p 2p 2p 2p
NURSINGTB.COM
, Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
c. Client understands the need for increased fluid intake.
2p 2p 2p 2p 2p 2p 2p
d. Client‘s skin remains cool and dry throughout hospitalization.
2p 2p 2p 2p 2p 2p 2p
ANS: 2 p A
This statement gives measurable data showing resolution of the problem of deficient fluid
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
volume that was identified in the nursing diagnosis statement. The other statements would n
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ot indicate that the problem of deficient fluid volume was resolved.
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
DIF: Cognitive Level: Application 2p 2p TOP: 2 p Nursing Process: Planning 2p 2p
7. Which of the following represents a nursing activity that is carried out during the evaluati
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
on phase of the nursing process?
2p 2p 2p 2p 2p
a. Determining if interventions have been effective in meeting client outcomes
2p 2p 2p 2p 2p 2p 2p 2p 2p
b. Documenting the nursing care plan in the progress notes in the medical record 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
c. Deciding whether the client‘s health problems have been completely resolved
2p 2p 2p 2p 2p 2p 2p 2p 2p
d. Asking the client to evaluate whether the nursing care provided was satisfactory
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ANS: 2 p A
Evaluation consists of determining whether the desired client outcomes have been met and
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
whether the nursing interventions were appropriate. The other responses do not describe the
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2
evaluation phase.
p 2p
DIF: Cognitive Level: Comprehension 2p 2p TOP: 2 p Nursing Process: Evaluation 2p 2p
8. Which of the following would the nurse perform during the assessment phase of the nursi
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
ng process?
2p
a. Obtains data with which to diagnose client problems
2p 2p 2p 2p 2p 2p 2p
b. Uses client data to develoNp pR
2p
S NIty
Uriori T nGursBin.
gCdOiagMnoses
2p
c. Teaches interventions to relieve client health problems
2p
2p 2p
2p 2p
2p
2p 2p
2p
2p
2p
2p
2p
2p
d. Assists the client to identify realistic outcomes to health problems
2p 2p 2p 2p 2p 2p 2p 2p 2p
ANS: 2 p A
During the assessment phase, the nurse gathers information about the client. The other resp
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
onses are examples of the intervention, diagnosis, and planning phases of the nursing proces
2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p 2p
s.
DIF: Cognitive Level: Knowledge 2p 2p TOP: 2 p Nursing Process: Assessment 2p 2p
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.
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d. Altered urinary elimination related to urinary tract infection
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ANS: 2 p 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 med
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ical 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 integrity‖
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uses the defining characteristics as the etiology.
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DIF: Cognitive Level: Comprehension 2p 2p TOP: 2 p Nursing Process: Diagnosis 2p 2p
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