Lewis’s Medical Surgical Nursing, 11th Edition by Harding Test Bank

Lewis’s Medical Surgical Nursing, 11th Edition by Harding Test Bank. Assessment and Management: Auditory Problems Chapter 22: Assessment: Integumentary System Chapter 23: Integumentary Problems Chapter 24: Burns Chapter 25: Assessment: Respiratory System Chapter 26: Upper Respiratory Problems Chapter 27: Lower Respiratory Problems Chapter 28: Obstructive Pulmonary Diseases Chapter 29: Assessment: Hematologic System Chapter 30: Hematologic Problems Chapter 31: Assessment: Cardiovascular System Chapter 32: Hypertension Chapter 33: Coronary Artery Disease and Acute Coronary Syndrome Chapter 34: Heart Failure Chapter 35: Dysrhythmias Chapter 36: Inflammatory and Structural Heart Disorders Chapter 37: Vascular Disorders Chapter 38: Assessment: Gastrointestinal System Chapter 39: Nutritional Problems Chapter 40: Obesity Chapter 41: Upper Gastrointestinal Problems Chapter 42: Lower Gastrointestinal Problems Chapter 43: Liver, Biliary Tract, and Pancreas Problems Chapter 44: Assessment: Urinary System Chapter 45: Renal and Urologic Problems Chapter 46: Acute Kidney Injury and Chronic Kidney Disease Chapter 47: Assessment: Endocrine System Chapter 48: Diabetes Mellitus Chapter 49: Endocrine Problems Chapter 50: Assessment: Reproductive System 13 21 28 38 48 54 59 71 79 91 101 105 117 129 148 165 175 184 196 216 227 233 245 259 270 282 305 325 332 353 364 375 394 406 420 435 450 458 469 478 499 523 543 553 573 590 600 622 642 Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 2 Chapter 51: Breast Disorders Chapter 52: Sexually Transmitted Infections Chapter 53: Female Reproductive Problems Chapter 54: Male Reproductive Problems Chapter 55: Assessment: Nervous System Chapter 56: Acute Intracranial Problems Chapter 57: Stroke Chapter 58: Chronic Neurologic Problems Chapter 59: Dementia and Delirium Chapter 60: Spinal Cord and Peripheral Nerve Problems Chapter 61: Assessment: Musculoskeletal System Chapter 62: Musculoskeletal Trauma and Orthopedic Surgery Chapter 63: Musculoskeletal Problems Chapter 64: Arthritis and Connective Tissue Diseases Chapter 65: Critical Care Chapter 66: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome Chapter 67: Acute Respiratory Failure and Acute Respiratory Distress Syndrome Chapter 68: Emergency and Disaster NursingA patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer on the left hipWhich nursing diagnosis is most appropriate? a. Impaired physical mobility related to left-sided paralysis b. Risk for impaired tissue integrity related to left-sided weakness c. Impaired skin integrity related to altered circulation and pressure d. Ineffective tissue perfusion related to inability to move independentlyANS: C Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 5 The patients major problem is the impaired skin integrity as demonstrated by the presence of a pressure ulcer.The nurse is able to treat the cause of altered circulation and pressure by frequently repositioning the patient. Although left-sided weakness is a problem for the patient, the nurse cannot treat the weakness. The risk fordiagnosis is not appropriate for this patient, who already has impaired tissue integrity. The patient does have ineffective tissue perfusion, but the impaired skin integrity diagnosis indicates more clearly what the health problem is. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity 5. A patient has been admitted to the hospital for surgery and tells the nurse, I do not feel comfortable leavingmy children with my parents. Which action should the nurse take next? a. Reassure the patient that these feelings are common for parents. b. Have the patient callthe children to ensure that they are doing well. c. Gather more data about the patients feelings about the child-care arrangements. d. Call the patients parents to determine whether adequate child care is being provided. ANS: C Since a complete assessment is necessary in order to identify a problem and choose an appropriate intervention, the nurses first action should be to obtain more information. The other actions may beappropriate, but more assessment is needed before the best intervention can be chosen. DIF: Cognitive Level: Apply (application) OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Psychosocial Integrity 6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to excessivediaphoresis. Which outcome would the nurse recognize as most appropriate for this patient? a. Patient has a balanced intake and output. b. Patients bedding is changed when it becomes damp. c. Patient understands the need for increased fluid intake. d. Patients skin remains cool and dry throughout hospitalization. ANS: A Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 6 This statement gives measurable data showing resolution of the problem of deficient fluid volume that wasidentified in the nursing diagnosis statement. The other statements would not indicate that the problem of deficient fluid volume was resolved. DIF: Cognitive Level: Apply (application) TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 7. A nurse asks the patient if pain was relieved after receiving medication. What is the purpose of theevaluation phase of the nursing process? a. To determine if interventions have been effective in meeting patient outcomes b. To document the nursing care plan in the progress notes of the medical record c. To decide whether the patients health problems have been completely resolved d. To establish if the patient agrees that the nursing care provided was satisfactory ANS: A Evaluation consists of determining whether the desired patient outcomes have been met and whether thenursing interventions were appropriate. The other responses do not describe the evaluation phase. DIF: Cognitive Level: Understand (comprehension) TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment 8. The nurse interviews a patient while completing the health history and physical examination. What is thepurpose of the assessment phase of the nursing process? a. To teach interventions that relieve health problems b. To use patient data to evaluate patient care outcomes c. To obtain data with which to diagnose patient problems d. To help the patient identify realistic outcomes for health problemsANS: C During the assessment phase, the nurse gathers information about the patient to diagnose patient problems. Theother responses are examples of the planning, intervention, and evaluation phases of the nursing process. DIF: Cognitive Level: Understand (comprehension) TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 9. Which nursing diagnosis statement is written correctly? Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 7 a. Altered tissue perfusion related to heart failure b. Risk for impaired tissue integrity related to sacral redness c. Ineffective coping related to response to biopsy test results d. Altered urinary elimination related to urinary tract infectionANS: C This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes a patients response to a health problem that can be treated by nursing. The use of a medical diagnosis as an etiology (asin the responses beginning Altered tissue perfusion and Altered urinary elimination) is not appropriate. The response beginning Risk for impaired tissue integrity uses the defining characteristic as the etiology. DIF: Cognitive Level: Understand (comprehension) TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment 10. The nurse admits a patient to the hospital and develops a plan of care. What components should the nurseinclude in the nursing diagnosis statement? a. The problem and the suggested patient goals or outcomes b. The problem with possible causes and the planned interventions c. The problem, its cause, and objective data that support the problem d. The problem with an etiology and the signs and symptoms of the problemANS: D Whenwriting nursing diagnoses, this format should be used: problem, etiology, and signs and symptoms. Thesubjective, as well as objective, data should be included in the defining characteristics. Interventions and outcomes are not included in the nursing diagnosis statement. DIF: Cognitive Level: Remember (knowledge) TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment 11. A nurse is caring for a patient with heart failure. Which task is appropriate for the nurse to delegate toexperienced unlicensed assistive personnel (UAP)? a. Monitor for shortness of breath or fatigue after ambulation. b. Instruct the patient about the need to alternate activity and rest. Test Bank - Lewis's Medical Surgical Nursing (11th Edition by Harding) 8 c. Obtain the patients blood pressure and pulse rate after ambulation. d. Determine whether the patient is ready to increase the activity level. ANS: C UAP education includes accurate vital sign measurement. Assessment and patient teaching require registerednurse education and scope of practice and cannot be delegated. DIF: Cognitive Level: Apply (application) OBJ: Special Questions: Delegation TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment 12. A nurse is caring for a group of patients on the medical-surgical unit with the help of one float registerednurse (RN), one unlicensed assistive personnel (UAP), and one licensed practical/vocational nurse (LPN/LVN). Which assignment, if delegated by the nurse, would be inappropriate? a. Measurement of a patients urine output by UAP b. Administration of oral medications by LPN/LVN c. Check for the presence of bowel sounds and flatulence by UAP d. Care of a patient with diabetes by RN who usually works on the pediatric unitANS: C Assessment requires RN education and scope of practice and cannot be delegated to an LPN/LVN or UAP.The other assignments made by the RN are appropriate. DIF: Cognitive Level: Apply (application) OBJ: Special Questions: Delegation TOP: Nursing Process: PlanningMSC: NCLEX: Safe and Effective Care Environment 13. Which task is appropriate for the nurse to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Complete the initial admission assessment and plan of care. b. Document teaching completed before a diagnostic procedure. c. Instruct a patient about low-fat, reduced sodium dietary restrictions. d. Obtain bedside blood glucose on a patient before insulin administration.