Test Bank Lewis Medical-Surgical Nursing: Assessment and Management of Clinical Problems 12th Edition By Harding & Kwong All Chapters ||Complete A+ Guide

,Chapter 01: Professional Nursing Practice Lewis:
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Medical-Surgical Nursing, 12th Edition
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MULTIPLE CHOICE wa




1. The nurse completes an admission database and explains that the plan of care and discharge goals will be
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developed with the patient‘s input. The patient states, ―How is this different from what the doctor does?‖ Which
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response would be most appropriate for the nurse to make?
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a. ―The role of the nurse is to administer medications and other treatments prescribed by your doctor.‖
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b. ―The nurse‘s job is to help the doctor by collecting information and
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communicating any problems that occur.‖
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c. ―Nurses perform many of the same procedures as the doctor, but nurses are with the patients for
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a longer time than the doctor.‖
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d. ―In addition to caring for you while you are sick, the nurses will assist you to develop an
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individualized plan to maintain your health.‖
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ANS: D wa




This response is consistent with the American Nurses Association (ANA) definition of nursing, which describes
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the role of nurses in promoting health. The other responses describe some of the dependent and collaborative
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functions of the nursing role but do not accurately describe the nurse‘s role in the health care system.
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DIF: Cognitive Level: Understand (comprehension) wa REF: 3 wa wa w a




TOP: w a Nursing Process: Implementation waMSC: NCLEX: Safe and Effective Care Environment wa w a wa wa wa wa wa




2. The nurse describes to a student nurse how to use evidence-based practice guidelines when caring for
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patients. Which statement, if made by the nurse, would be the most accurate?
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a. ―Inferences from clinical research studies are used as a guide.‖ wa wa wa wa wa wa wa wa wa




b. ―Patient care is based on clinical judgment, experience, and traditions.‖
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c. ―Data are evaluated to show that the patient outcomes are consistently met.‖
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d. ―Recommendations are based on research, clinical expertise, and patient preferences.‖ wa wa wa wa wa wa wa wa wa




ANS: D wa




Evidence-based practice (EBP) is the use of the best research-based evidence combined with clinician expertise.
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Clinical judgment based on the nurse‘s clinical experience is part of EBP, but clinical decision making should
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also incorporate current research and research-based guidelines. Evaluation of patient outcomes is important,
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but interventions should be based on research from randomized control studies with a large number of subjects.
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DIF: Cognitive Level: Remember (knowledge) wa wa wa REF: 15 w a




TOP: w a Nursing Process: Planning wa wa MSC: NCLEX: Safe and Effective Care Environment
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3. The nurse teaches a student nurse about how to apply the nursing process when providing patient care.
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Which statement, if made by the student nurse, indicates that teaching was successful?
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a. ―The nursing process is a scientific-based method of diagnosing the patient‘s health care
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problems.‖ wa




b. ―The nursing process is a problem-solving tool used to identify and treat patients‘
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, health care needs.‖ wa wa




c. ―The nursing process is used primarily to explain nursing interventions to other health care
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professionals.‖ wa




d. ―The nursing process is based on nursing theory that incorporates the
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biopsychosocial nature of humans.‖
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ANS: B wa




The nursing process is a problem-solving approach to the identification and treatment of patients‘ problems.
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Diagnosis is only one phase of the nursing process. The primary use of the nursing process is in patient care, not
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to establish nursing theory or explain nursing interventions to other health care professionals.
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DIF: Cognitive Level: Understand (comprehension) waREF: 5 wa wa w a




TOP: w a Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
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4. A patient has been admitted to the hospital for surgery and tells the nurse, ―I do not feel comfortable leaving
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my children with my parents.‖ Which action should the nurse take next?
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a. Reassure the patient that these feelings are common for parents. wa wa wa wa wa wa wa wa wa




b. Have the patient call the children to ensure that they are doing well.
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c. Gather more data about the patient‘s feelings about the child-care arrangements.
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d. Call the patient‘s parents to determine whether adequate child care is being provided.
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ANS: C wa




Because 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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DIF: Cognitive Level: Apply (application) wa wa wa REF: 6
OBJ: Special Questions: Prioritization
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NCLEX: Psychosocial Integrity
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5. A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer on the left hip.
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Which nursing diagnosis is most appropriate?
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a. Impaired physical mobility related to left-sided paralysis wa wa wa wa wa wa




b. Risk for impaired tissue integrity related to left-sided weakness
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c. Impaired skin integrity related to altered circulation and pressure wa wa wa wa wa wa wa wa




d. Ineffective tissue perfusion related to inability to move independently wa wa wa wa wa wa wa wa




ANS: C wa




The patient‘s major problem is the impaired skin integrity as demonstrated by the presence of a pressure ulcer.
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The nurse is able to treat the cause of altered circulation and pressure by frequently repositioning the patient.
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Although left-sided weakness is a problem for the patient, the nurse cannot treat the weakness. The ―risk for‖
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diagnosis is not appropriate for this patient, who already has impaired tissue integrity. The patient does have
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ineffective tissue perfusion, but the impaired skin integrity diagnosis indicates more clearly what the health
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problem is.
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DIF: Cognitive Level: Apply (application) wa wa wa REF: 7
TOP: w a Nursing Process: Diagnosis wa wa MSC: NCLEX: Physiological Integrity w a wa wa

, 6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to excessive
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diaphoresis. Which outcome would the nurse recognize as appropriate for this patient?
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a. Patient has a balanced intake and output. wa wa wa wa wa wa




b. Patient‘s bedding is changed when it becomes damp. wa wa wa wa wa wa wa




c. Patient understands the need for increased fluid intake. wa wa wa wa wa wa wa




d. Patient‘s skin remains cool and dry throughout hospitalization. wa wa wa wa wa wa wa




ANS: A wa




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: Apply (application) wa wa wa REF: 7
TOP: w a Nursing Process: Planning wa wa MSC: NCLEX: Physiological Integrity w a wa wa




7. A nurse asks the patient if pain was relieved after receiving medication. What is the purpose of the evaluation
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phase of the nursing process?
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a. To determine if interventions have been effective in meeting patient outcomes
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b. To document the nursing care plan in the progress notes of the medical record
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c. To decide whether the patient‘s health problems have been completely resolved
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d. To establish if the patient agrees that the nursing care provided was satisfactory
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ANS: A wa




Evaluation consists of determining whether the desired patient outcomes have been met and whether the
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nursing interventions were appropriate. The other responses do not describe the evaluation phase.
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DIF: w a w Cognitive Level: Understand (comprehension)
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TOP: w a Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
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8. The nurse interviews a patient while completing the health history and physical examination. What is the
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purpose of the assessment phase of the nursing process?
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a. To teach interventions that relieve health problems
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b. To use patient data to evaluate patient care outcomes
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c. To obtain data with which to diagnose patient problems
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d. To help the patient identify realistic outcomes for health problems
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ANS: C wa




During the assessment phase, the nurse gathers information about the patient to diagnose patient problems. The
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other responses are examples of the planning, intervention, and evaluation phases of the nursing process.
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DIF: w a w Cognitive Level: Understand (comprehension)
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TOP: w a Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
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9. Which nursing diagnosis statement is written correctly?
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a. Altered tissue perfusion related to heart failure wa wa wa wa wa wa




b. Risk for impaired tissue integrity related to sacral redness
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c. Ineffective coping related to response to biopsy test results wa wa wa wa wa wa wa wa




d. Altered urinary elimination related to urinary tract infection wa wa wa wa wa wa wa