Updated/Latest Lewis’s Medical-Surgical Nursing in Canada 4th Edition Test Bank Comprehensive Examination Questions and Answers Study Guide for Adult Health Nursing Medical Surgical Care Pathophysiology Clinical Reasoning Patient Assessment Nursing Interv

Lewis Medical-Surgical Nursing in Canada 4th Edition Tes Bank J




Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition


MULTIPLE CHOICE :

1. The nurse is caring for a client with a new diagnosis of pneumonia and
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explains to the client that together they will plan the client’s care and set
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goals for discharge. The client asks, “How is that different from what the
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doctor does?” Which response by the nurse is most appropriate?
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a. “The role ofthe nurse is to administer medications and other treatments prescribed
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by your doctor.” J J




b. “The nurse’s job isto help the doctor by collecting data and communicating when there
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are problems.” J




c. “Nurses perform many of the procedures done by physicians, but nurses are here in
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the hospital for a longer time than doctors.”
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d. “In addition to caring for you while you are sick, the nurses will assist you to
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develop an individualized plan to maintain your health.” J J J J J J J




ANS: D J




This response is consistent with the Canadian Nurses Association (CNA) definition of nursing. Registered
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nurses are self-regulated health care professionals who work autonomously and in collaboration with others.
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RNs enable individuals, families, groups, communities and populations to achieve their optimal level of
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health. RNs coordinate health care, deliver direct services, and support clients in their self-care decisions and
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actions in situations of health, illness, injury, and disability in all stages of life. The other responses describe
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some of the dependent and collaborative functions of the nursing role but do not accurately describe the
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nurse’s role in the health care system.
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DIF: Cognitive Level: Comprehension TOP: NursingProcess: Implementation J J J J J J




MSC: NCLEX: Safe and Effective Care Environment
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2. When caring for clients using evidence-informed practice, which ofthe following does the nurse use?
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a. Clinicaljudgement based on experience J J J J




b. Evidence from a clinical research study J J J J J




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




ANS: C J




Evidence-informed nursing practice is a continuous interactive process involving the explicit, J J J J J J J J J J J




conscientious, and judicious consideration ofthe best available evidence to provide care. Four primary J J J J J J J J J J J J J J




elements are: (a) clinical state, setting, and circumstances; (b) client preferences and actions; (c) best
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research evidence, and (d) health care resources. Clinical judgement based on the nurse’s clinical
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experience is part of EIP, but clinical decision making also should incorporate current research and
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research-based guidelines. Evidence from one clinical research study does not provide an adequate J J J J J J J J J J J J J




substantiation for interventions. Evaluation of client outcomes isimportant, but interventions should be
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based on research from randomized control studies with a large number of subjects.
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, Lewis Medical-Surgical Nursing in Canada 4th Edition Tes Bank J




DIF: Cognitive Level: Comprehension TOP: NursingProcess: Planning J J J J J J




MSC: NCLEX: Safe and Effective Care Environment
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3. Which of the following best explains the nurses’ primaryuse ofthe nursing process when providing care to
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clients?
a. Toexplain 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. Toestablish nursing theorythat incorporates the biopsychosocial nature of humans
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ANS: B J




The nursing process is an assertive problem-solving approach to the identification and treatment of clients’
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problems. Diagnosis is only one phase of the nursing process. The primary use of the nursing process is in
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client care, not to establish nursing theory or explain nursing interventions to other health care professionals.
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DIF: Cognitive Level: Comprehension TOP: NursingProcess: Implementation J J J J J J




MSC: NCLEX: Safe and Effective Care Environment
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4. The nurse is caring for a critically ill client in the intensive care unit and plans an every-2-hour turning
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schedule to prevent skin breakdown. Which type of nursing function is demonstrated with this turning
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schedule?
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: D J




When implementing collaborative nursing actions, the nurse is responsible primarily for monitoring for
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complications of acute illness or providing care to prevent or treat complications. Independent nursing
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actions are focused on health promotion, illness prevention, and client advocacy. A dependent action would
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require a physician order to implement. Cooperative nursing functions are not described as one of the
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formal nursing functions.
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DIF: Cognitive Level: Application TOP: NursingProcess: Implementation J J J J J J




MSC: NCLEX: Safe and Effective Care Environment
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5. The nurse is caring for a client who has been admitted to the hospital for surgery and tells the nurse, “I do not
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feel right about leaving my children with my neighbour.” Which action should the nurse take next?
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a. Reassure the client that these feelings are common for parents. J J J J J J J J J




b. Have the client call the children to ensure that they are doing well.
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c. Callthe 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 J




Since a complete assessment is necessary in order to identify a problem and choose an appropriate
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intervention, the nurse’s first action should be to obtain more information. The other actions may be
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appropriate, but more assessment is needed before the best intervention can be chosen.
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, Lewis Medical-Surgical Nursing in Canada 4th Edition Tes Bank J




DIF: Cognitive Level: Application J J TOP: NursingProcess: Assessment J J J J




MSC: NCLEX: Psychosocial Integrity
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6. The nurse is caring for a client who has left-sided paralysis as the result of a stroke and assesses a
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pressure injury on the client’s left hip. Which of the following is the most appropriate nursing
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diagnosis for this client? J J J




a. Impaired physical mobilityrelated to decrease in muscle control(left-sided
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paralysis)
b. Risk for impaired tissue integrity as evidenced byinsufficient knowledge about
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protecting tissue integrity J J




c. Impaired skin integrity related to pressure over bony prominence (impaired
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circulation)
d. Ineffective peripheraltissue perfusion related to sedentary lifestyle J J J J J J J




ANS: C J




The client’s major problem is the impaired skin integrity as demonstrated by the presence ofa pressure injury.
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The nurse is able to treat the cause of impaired circulation and pressure over bony prominence by frequently
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repositioning the client. Although left-sided weakness is a problem for the client, the nurse cannot treat the
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weakness. The “risk for” diagnosis is not appropriate for this client, who already has impaired tissue
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integrity. The client does have ineffective peripheral tissue perfusion, but the impaired skin integrity
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diagnosis indicates more clearly what the health problem is.
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DIF: Cognitive Level: Application J J TOP: NursingProcess: Diagnosis J J J J




MSC: NCLEX: Physiological Integrity
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7. The nurse caring for a client with an infection has a nursing diagnosis of deficient fluid volume related to
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excessive fluid loss through normal route (diaphoresis). Which of the following is an appropriate client
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outcome?
a. Client has a balanced intake and output. J J J J J J




b. Client’s bedding is changed when it becomes damp. J J J J J J J




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 J




This statement gives measurable data showing resolution of the problem of deficient fluid volume that was
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identified in the nursing diagnosis statement. The other statements would not indicate that the problem of
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deficient fluid volume was resolved.
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DIF: Cognitive Level: Application J J TOP: NursingProcess: Planning J J J J




MSC: NCLEX: Physiological Integrity
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8. Which of the following represents a nursing activity that is carried out during the evaluation phase of the
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nursing process? J




a. Determining if interventions have been effective in meeting client outcomes. J J J J J J J J J




b. Documenting the nursing care plan in the progress notes in the medical record. J J J J J J J J J J J J




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 J

, Lewis Medical-Surgical Nursing in Canada 4th Edition Tes Bank J




Evaluation consists of determining whether the desired client outcomes have been met and whether the nursing
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interventions were appropriate. The other responses do not describe the evaluation phase.
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DIF: Cognitive Level: Comprehension TOP: NursingProcess: Evaluation J J J J J J




MSC: NCLEX: Safe and Effective Care Environment
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9. Which of the following would the nurse perform during the assessment phase ofthe nursing process?
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a. Obtains data with whichto diagnose client problems. J J J J J J J




b. Uses client data to develop priority nursing diagnoses.
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c. Teaches interventions to relieve client health problems. J J J J J J




d. Assists the client to identify realistic outcomes to health problems.
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ANS: A J




During the assessment phase, the nurse gathers information about the client. The other responses are examples
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of the intervention, diagnosis, and planning phases of the nursing process.
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DIF: Cognitive Level: Knowledge TOP: NursingProcess: Assessment J J J J J J




MSC: NCLEX: Safe and Effective Care Environment
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10. 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. J J J J J J




b. Risk for impaired tissue integrityrelated to sacralredness.
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c. Ineffective coping related to insufficient sense of control. J J J J J J J




d. Altered urinary elimination related to urinary tract infection.
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ANS: C J




This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes a client’s
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response to a health problem that can be treated by nursing. The use of a medical diagnosis (as in the responses
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beginning “Altered tissue perfusion” and “Altered urinary elimination”) is not appropriate.
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The response beginning “Risk for impaired tissue integrity” uses the defining characteristics as the etiology.
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DIF: Cognitive Level: Comprehension TOP: NursingProcess: Diagnosis J J J J J J




MSC: NCLEX: Safe and Effective Care Environment
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11. Which of the following includes the components required for a complete nursing diagnosis statement?
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a. A problem and the suggested client goals or outcomes.
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b. A problem, its cause, and objective data that support the problem.
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c. A problem with all its possible causes and the planned interventions.
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d. A problem with its etiology and the signs and symptoms ofthe problem.
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ANS: D J




The PES format is used when writing nursing diagnoses. The subjective, as well as objective, data should be
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included in the defining characteristics. Interventions and outcomes are not included in the nursing diagnosis
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statement.

DIF: Cognitive Level: Knowledge TOP: NursingProcess: Diagnosis J J J J J J




MSC: NCLEX: Safe and Effective Care Environment
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