, Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada
MULTIPLE CHOICE
1. When caring for clients using evidence-informed practice, which of the following
does the nurse use?
a. Clinical judgement based on experience
b. Evidence from a clinical research study
c. The best available evidence to guide clinical expertise
d. Evaluation of data showing that the client outcomes are met
Answ: C
Evidence-informed nursing practice is a continuous interactive process involving the
explicit, conscientious, and judicious consideration of the best available evidence to
provide care. Four primary elements are: (a) clinical state, setting, and circumstances;
(b) client preferences and actions; (c) best research evidence; and (d) health care
resources. Clinical judgement based on the nurse’s clinical experience is part of EIP,
but clinical decision making also should incorporate current research and research-
based guidelines. Evidence from one clinical research study does not provide an
adequate substantiation for interventions. Evaluation of client outcomes is important,
but interventions should be based on research from randomized control studies with a
large number of subjects.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning
2. Which of the following best e x p l a i n s t h e n u r s e s ’ pr imary use of the nursing process when
N R I G B. C M
providing care to USNT O
clients?
, a. To explain nursing interventions to other health care professionals
b. As a problem-solving tool to identify and treat clients’ health care needs
c. As a scientific-based process of diagnosing the client’s health care problems
d. To establish nursing theory that incorporates the biopsychosocial nature of humans
Answ: B
The nursing process is an assertive problem-solving approach to the identification and
treatment of clients’ problems. Diagnosis is only one phase of the nursing process. The
primary use of the nursing process is in client care, not to establish nursing theory or
explain nursing interventions to other health care professionals.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation
3. The nurse is caring for a critically ill client in the intensive care unit and plans an every
2-hour turning schedule to prevent skin breakdown. Which type of nursing function is
demonstrated with this turning schedule?
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
Answ: D
When implementing collaborative nursing actions, the nurse is responsible primarily
for monitoring for complications of acute illness or providing care to prevent or treat
complications. Independent nursing actions are focused on health promotion, illness
prevention, and client advocacy. A dependent action would require a physician order to
implement. Cooperative nursing functions are not described as one of the formal
nursing functions.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
4. The nurse is caring for a client who has been admitted to the hospital for surgery and
tells the nurse, “I do not feel right about leaving my children with my neighbour.”
Want to earn $1.236
extra per year?
, Which action should the nurse take next?
a. Reassure the client that these feelings are common for parents.
b. Have the client call the children to ensure that they are doing well.
c. Call the neighbour to determine whether adequate childcare is being provided.
d. Gather more data about the client’s feelings about the childcare arrangements.
Answ: D
Since a complete assessment is necessary in order to identify a problem and choose an
appropriate intervention, the nurse’s first action should be to obtain more information.
The other actions may be appropriate, but more assessment is needed before the best
intervention can be chosen.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
5. The nurse is caring for a client who has left-sided paralysis as the result of a
stroke and assesses a pressure injury on the client’s left hip. Which of the
following is the most
N R I G B.C M
appropriate nursing diagno sis fU ortShis O
aN. ImpTaired physical mobility related to decrease in muscle control (left-sided
clien t?
paralysis)
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge
about protecting tissue integrity
c. Impaired skin integrity related to pressure over bony prominence
(impaired circulation)
d. Ineffective tissue perfusion related to sedentary lifestyle
Answ: C
The client’s major problem is the impaired skin integrity as demonstrated by the
presence of a pressure injury. The nurse is able to treat the cause of altered circulation
and pressure by frequently repositioning the client. Although left-sided weakness is a
problem for the client, the nurse cannot treat the weakness. The “risk for” diagnosis is
not appropriate for this client, who already has impaired tissue integrity. The client
does have ineffective tissue perfusion, but the impaired skin integrity diagnosis
indicates more clearly what the health problem is.
Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada
MULTIPLE CHOICE
1. When caring for clients using evidence-informed practice, which of the following
does the nurse use?
a. Clinical judgement based on experience
b. Evidence from a clinical research study
c. The best available evidence to guide clinical expertise
d. Evaluation of data showing that the client outcomes are met
Answ: C
Evidence-informed nursing practice is a continuous interactive process involving the
explicit, conscientious, and judicious consideration of the best available evidence to
provide care. Four primary elements are: (a) clinical state, setting, and circumstances;
(b) client preferences and actions; (c) best research evidence; and (d) health care
resources. Clinical judgement based on the nurse’s clinical experience is part of EIP,
but clinical decision making also should incorporate current research and research-
based guidelines. Evidence from one clinical research study does not provide an
adequate substantiation for interventions. Evaluation of client outcomes is important,
but interventions should be based on research from randomized control studies with a
large number of subjects.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning
2. Which of the following best e x p l a i n s t h e n u r s e s ’ pr imary use of the nursing process when
N R I G B. C M
providing care to USNT O
clients?
, a. To explain nursing interventions to other health care professionals
b. As a problem-solving tool to identify and treat clients’ health care needs
c. As a scientific-based process of diagnosing the client’s health care problems
d. To establish nursing theory that incorporates the biopsychosocial nature of humans
Answ: B
The nursing process is an assertive problem-solving approach to the identification and
treatment of clients’ problems. Diagnosis is only one phase of the nursing process. The
primary use of the nursing process is in client care, not to establish nursing theory or
explain nursing interventions to other health care professionals.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation
3. The nurse is caring for a critically ill client in the intensive care unit and plans an every
2-hour turning schedule to prevent skin breakdown. Which type of nursing function is
demonstrated with this turning schedule?
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
Answ: D
When implementing collaborative nursing actions, the nurse is responsible primarily
for monitoring for complications of acute illness or providing care to prevent or treat
complications. Independent nursing actions are focused on health promotion, illness
prevention, and client advocacy. A dependent action would require a physician order to
implement. Cooperative nursing functions are not described as one of the formal
nursing functions.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
4. The nurse is caring for a client who has been admitted to the hospital for surgery and
tells the nurse, “I do not feel right about leaving my children with my neighbour.”
Want to earn $1.236
extra per year?
, Which action should the nurse take next?
a. Reassure the client that these feelings are common for parents.
b. Have the client call the children to ensure that they are doing well.
c. Call the neighbour to determine whether adequate childcare is being provided.
d. Gather more data about the client’s feelings about the childcare arrangements.
Answ: D
Since a complete assessment is necessary in order to identify a problem and choose an
appropriate intervention, the nurse’s first action should be to obtain more information.
The other actions may be appropriate, but more assessment is needed before the best
intervention can be chosen.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
5. The nurse is caring for a client who has left-sided paralysis as the result of a
stroke and assesses a pressure injury on the client’s left hip. Which of the
following is the most
N R I G B.C M
appropriate nursing diagno sis fU ortShis O
aN. ImpTaired physical mobility related to decrease in muscle control (left-sided
clien t?
paralysis)
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge
about protecting tissue integrity
c. Impaired skin integrity related to pressure over bony prominence
(impaired circulation)
d. Ineffective tissue perfusion related to sedentary lifestyle
Answ: C
The client’s major problem is the impaired skin integrity as demonstrated by the
presence of a pressure injury. The nurse is able to treat the cause of altered circulation
and pressure by frequently repositioning the client. Although left-sided weakness is a
problem for the client, the nurse cannot treat the weakness. The “risk for” diagnosis is
not appropriate for this client, who already has impaired tissue integrity. The client
does have ineffective tissue perfusion, but the impaired skin integrity diagnosis
indicates more clearly what the health problem is.
