Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
NURSINGTB.COM
, Medical-
Chapter 01: Introduction
m5 to Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
m5 m5 m5
Surgical Nursing Practice in Canada Lewis: Medical-
m5 m5 m5 m5 m5 m5
Surgical Nursing in Canada, 5th Canadian Edition
m5 m5 m5 m5 m5 m5
MULTIPLE CHOICE m5
1. When caring for clients using evidence-
m5 m5 m5 m5 m5
informed practice, which of the following does the nurse use?
m5 m5 m5 m5 m5 m5 m5 m5 m5
a. Clinical judgement based on experience m5 m5 m5 m5
b. Evidence from a clinical research study m5 m5 m5 m5 m5
c. The best available evidence to guide clinical expertise
m5 m5 m5 m5 m5 m5 m5
d. Evaluation of data showing that the client outcomes are met
m5 m5 m5 m5 m5 m5 m5 m5 m5
ANS: m 5 C
Evidence-
informed nursing practice is a continuous interactive process involving the explicit, consc
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ientious, and judicious consideration of the best available evidence to provide care. Four
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
primary elements are: (a) clinical state, setting, and circumstances; (b) client preferences
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m
5and actions; (c) best research evidence; and (d) health care resources. Clinical judgement
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
based on the nurse‘s clinical experience is part of EIP, but clinical decision making also
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
m5should incorporate current research and research-
m5 m5 m5 m5 m5
based guidelines. Evidence from one clinical research study does not provide an adequat
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
e substantiation for interventions. Evaluation of client outcomes is important, but interve
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ntions should be based on research from randomized control studies with a large numbe
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
r of subjects.
m5 m5
DIF: Cognitive Level: Comprehension m5 m5 TOP: m 5 Nursing Process: Planning m5 m5
2. Which of the following best e xp l a i n s th e n u r s e s ‘ primary use of the nursing process
m5
N R I G B . C M
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m 5 m5 m5 m5 m5 m5
m5 when providing care to clients?
m5
USNT O m5 m5 m5
m5 m5 m5
a. To explain nursing interventions to other health care professionals
m5 m5 m5 m5 m5 m5 m5 m5
b. As a problem-solving tool to identify and treat clients‘ health care needs
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
c. As a scientific-based process of diagnosing the client‘s health care problems
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
d. To establish nursing theory that incorporates the biopsychosocial nature of humans
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ANS: m 5 B
The nursing process is an assertive problem-
m5 m5 m5 m5 m5 m5
solving approach to the identification and treatment of clients‘ problems. Diagnosis is on
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ly one phase of the nursing process. The primary use of the nursing process is in client
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
care, not to establish nursing theory or explain nursing interventions to other health care
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
professionals.
DIF: Cognitive Level: Comprehension m5 m5 TOP: m 5 Nursing Process: Implementation m5 m5
3. The nurse is caring for a critically ill client in the intensive care unit and plans an every
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m
2-
5
hour turning schedule to prevent skin breakdown. Which type of nursing function is de
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
monstrated with this turning schedule? m5 m5 m5 m5
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: m 5 D
NURSINGTB.COM
, Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
When implementing collaborative nursing actions, the nurse is responsible primarily for
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
monitoring for complications of acute illness or providing care to prevent or treat compl
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ications. Independent nursing actions are focused on health promotion, illness prevention,
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
and client advocacy. A dependent action would require a physician order to implement.
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
Cooperative nursing functions are not described as one of the formal nursing functions.
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
DIF: Cognitive Level: Application m5 m5 TOP: m 5 Nursing Process: Implementation
m5 m5
4. The nurse is caring for a client who has been admitted to the hospital for surgery and t
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ells the nurse, ―I do not feel right about leaving my children with my neighbour.‖ W
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
hich action should the nurse take next?
m5 m5 m5 m5 m5 m5
a. Reassure the client that these feelings are common for parents.
m5 m5 m5 m5 m5 m5 m5 m5 m5
b. Have the client call the children to ensure that they are doing well.
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
c. Call the neighbour to determine whether adequate childcare is being provided.
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
d. Gather more data about the client‘s feelings about the childcare arrangements.
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ANS: m 5 D
Since a complete assessment is necessary in order to identify a problem and choose an
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
appropriate intervention, the nurse‘s first action should be to obtain more information. T
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
he other actions may be appropriate, but more assessment is needed before the best interv
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ention can be chosen. m5 m5 m5
DIF: Cognitive Level: Application m5 m5 TOP: m 5 Nursing Process: Assessment m5 m5
5. The nurse is caring for a client who has left-
m5 m5 m5 m5 m5 m5 m5 m5 m5
sided paralysis as the result of a stroke and assesses a pressure injury on the clie
nt‘s left h i p . W hich ofNtheRfollowing
I G is Bthe
.CmostM appropriate nursing diagnosis f Uo r
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
m 5 m 5 m 5 m 5 5
m 5
m m 5
m5 m5 m5 m
5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
t Sh i s cNl i e nTt ?
m5 m5 m5 m5 O
m5 m5 m5 m5
a. Impaired physical mobility related to decrease in muscle control (left-sided
m5 m5 m5 m5 m5 m5 m5 m5 m5
paralysis)
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge ab
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
out protecting tissue integrity
m5 m5 m5
c. Impaired skin integrity related to pressure over bony prominence (impai
m5 m5 m5 m5 m5 m5 m5 m5 m5
red circulation) m5
d. Ineffective tissue perfusion related to sedentary lifestyle m5 m5 m5 m5 m5 m5
ANS: m 5 C
The client‘s major problem is the impaired skin integrity as demonstrated by the presence
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m
of a pressure injury. The nurse is able to treat the cause of altered circulation and press
5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ure by frequently repositioning the client. Although left-
m5 m5 m5 m5 m5 m5 m5
sided weakness is a problem for the client, the nurse cannot treat the weakness. The ―ri
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
sk for‖ diagnosis is not appropriate for this client, who already has impaired tissue integri
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ty. The client does have ineffective tissue perfusion, but the impaired skin integrity diag
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
nosis indicates more clearly what the health problem is.
m5 m5 m5 m5 m5 m5 m5 m5
DIF: Cognitive Level: Application m5 m5 TOP: m 5 Nursing Process: Diagnosis m5 m5
6. The nurse caring for a client with an infection has a nursing diagnosis of deficien
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
t fluid volume related to excessive diaphoresis. Which of the following is an appro
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
priate client outcome? m5 m5
a. Client has a balanced intake and output.
m5 m5 m5 m5 m5 m5
b. Client‘s bedding is changed when it becomes damp.
m5 m5 m5 m5 m5 m5 m5
NURSINGTB.COM
, Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
c. Client understands the need for increased fluid intake.
m5 m5 m5 m5 m5 m5 m5
d. Client‘s skin remains cool and dry throughout hospitalization.
m5 m5 m5 m5 m5 m5 m5
ANS: m 5 A
This statement gives measurable data showing resolution of the problem of deficient flui
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
d volume that was identified in the nursing diagnosis statement. The other statements wou
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ld not indicate that the problem of deficient fluid volume was resolved.
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
DIF: Cognitive Level: Application m5 m5 TOP: m 5 Nursing Process: Planning m5 m5
7. Which of the following represents a nursing activity that is carried out during the evalu
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ation phase of the nursing process?
m5 m5 m5 m5 m5
a. Determining if interventions have been effective in meeting client outcomes
m5 m5 m5 m5 m5 m5 m5 m5 m5
b. Documenting the nursing care plan in the progress notes in the medical record
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
c. Deciding whether the client‘s health problems have been completely resolved
m5 m5 m5 m5 m5 m5 m5 m5 m5
d. Asking the client to evaluate whether the nursing care provided was satisfactory
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ANS: m 5 A
Evaluation consists of determining whether the desired client outcomes have been met a
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
nd whether the nursing interventions were appropriate. The other responses do not describ
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
e the evaluation phase.
m5 m5 m5
DIF: Cognitive Level: Comprehension m5 m5 TOP: m 5 Nursing Process: Evaluationm5 m5
8. Which of the following would the nurse perform during the assessment phase of the nu
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
rsing process? m5
a. Obtains data with which to diagnose client problems
m5 m5 m5 m5 m5 m5 m5
b. Uses client data to develoNp p R
m5 ri o riIt y nGursB
in.
m5gCdiagMnoses m5 m5 m5 m5 m 5 m5
m5 m5 m5
c. Teaches interventions to relieve client health problems
m5 m5 m5 m5 m5 m5
d. Assists the client to identify realistic outcomes to health problems
m5 m5 m5 m5 m5 m5 m5 m5 m5
ANS: m 5 A
During the assessment phase, the nurse gathers information about the client. The other r
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
esponses are examples of the intervention, diagnosis, and planning phases of the nursing
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
process.
DIF: Cognitive Level: Knowledge m5 m5 TOP: m 5 Nursing Process: Assessmentm5 m5
9. Which of the following is an example of a correctly written nursing diagnosis statement?
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
a. Altered tissue perfusion related to heart failure
m5 m5 m5 m5 m5 m5
b. Risk for impaired tissue integrity related to sacral redness
m5 m5 m5 m5 m5 m5 m5 m5
c. Ineffective coping related to insufficient sense of control.
m5 m5 m5 m5 m5 m5 m5
d. Altered urinary elimination related to urinary tract infection
m5 m5 m5 m5 m5 m5 m5
ANS: m 5 C
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that descr
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ibes a client‘s response to a health problem that can be treated by nursing. The use of
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m
5a medical diagnosis (as in the responses beginning ―Altered tissue perfusion‖ and ―Alt
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ered urinary elimination‖) is not appropriate. The response beginning ―Risk for impaire
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
d tissue integrity‖ uses the defining characteristics as the etiology.
m5 m5 m5 m5 m5 m5 m5 m5 m5
DIF: Cognitive Level: Comprehension m5 m5 TOP: m 5 Nursing Process: Diagnosis m5 m5
NURSINGTB.COM
Surgical Nursing in Canada 5th Edition Lewi Test Bank
NURSINGTB.COM
, Medical-
Chapter 01: Introduction
m5 to Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
m5 m5 m5
Surgical Nursing Practice in Canada Lewis: Medical-
m5 m5 m5 m5 m5 m5
Surgical Nursing in Canada, 5th Canadian Edition
m5 m5 m5 m5 m5 m5
MULTIPLE CHOICE m5
1. When caring for clients using evidence-
m5 m5 m5 m5 m5
informed practice, which of the following does the nurse use?
m5 m5 m5 m5 m5 m5 m5 m5 m5
a. Clinical judgement based on experience m5 m5 m5 m5
b. Evidence from a clinical research study m5 m5 m5 m5 m5
c. The best available evidence to guide clinical expertise
m5 m5 m5 m5 m5 m5 m5
d. Evaluation of data showing that the client outcomes are met
m5 m5 m5 m5 m5 m5 m5 m5 m5
ANS: m 5 C
Evidence-
informed nursing practice is a continuous interactive process involving the explicit, consc
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ientious, and judicious consideration of the best available evidence to provide care. Four
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
primary elements are: (a) clinical state, setting, and circumstances; (b) client preferences
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m
5and actions; (c) best research evidence; and (d) health care resources. Clinical judgement
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
based on the nurse‘s clinical experience is part of EIP, but clinical decision making also
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
m5should incorporate current research and research-
m5 m5 m5 m5 m5
based guidelines. Evidence from one clinical research study does not provide an adequat
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
e substantiation for interventions. Evaluation of client outcomes is important, but interve
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ntions should be based on research from randomized control studies with a large numbe
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
r of subjects.
m5 m5
DIF: Cognitive Level: Comprehension m5 m5 TOP: m 5 Nursing Process: Planning m5 m5
2. Which of the following best e xp l a i n s th e n u r s e s ‘ primary use of the nursing process
m5
N R I G B . C M
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m 5 m5 m5 m5 m5 m5
m5 when providing care to clients?
m5
USNT O m5 m5 m5
m5 m5 m5
a. To explain nursing interventions to other health care professionals
m5 m5 m5 m5 m5 m5 m5 m5
b. As a problem-solving tool to identify and treat clients‘ health care needs
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
c. As a scientific-based process of diagnosing the client‘s health care problems
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
d. To establish nursing theory that incorporates the biopsychosocial nature of humans
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ANS: m 5 B
The nursing process is an assertive problem-
m5 m5 m5 m5 m5 m5
solving approach to the identification and treatment of clients‘ problems. Diagnosis is on
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ly one phase of the nursing process. The primary use of the nursing process is in client
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
care, not to establish nursing theory or explain nursing interventions to other health care
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
professionals.
DIF: Cognitive Level: Comprehension m5 m5 TOP: m 5 Nursing Process: Implementation m5 m5
3. The nurse is caring for a critically ill client in the intensive care unit and plans an every
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m
2-
5
hour turning schedule to prevent skin breakdown. Which type of nursing function is de
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
monstrated with this turning schedule? m5 m5 m5 m5
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: m 5 D
NURSINGTB.COM
, Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
When implementing collaborative nursing actions, the nurse is responsible primarily for
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
monitoring for complications of acute illness or providing care to prevent or treat compl
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ications. Independent nursing actions are focused on health promotion, illness prevention,
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
and client advocacy. A dependent action would require a physician order to implement.
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
Cooperative nursing functions are not described as one of the formal nursing functions.
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
DIF: Cognitive Level: Application m5 m5 TOP: m 5 Nursing Process: Implementation
m5 m5
4. The nurse is caring for a client who has been admitted to the hospital for surgery and t
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ells the nurse, ―I do not feel right about leaving my children with my neighbour.‖ W
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
hich action should the nurse take next?
m5 m5 m5 m5 m5 m5
a. Reassure the client that these feelings are common for parents.
m5 m5 m5 m5 m5 m5 m5 m5 m5
b. Have the client call the children to ensure that they are doing well.
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
c. Call the neighbour to determine whether adequate childcare is being provided.
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
d. Gather more data about the client‘s feelings about the childcare arrangements.
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ANS: m 5 D
Since a complete assessment is necessary in order to identify a problem and choose an
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
appropriate intervention, the nurse‘s first action should be to obtain more information. T
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
he other actions may be appropriate, but more assessment is needed before the best interv
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ention can be chosen. m5 m5 m5
DIF: Cognitive Level: Application m5 m5 TOP: m 5 Nursing Process: Assessment m5 m5
5. The nurse is caring for a client who has left-
m5 m5 m5 m5 m5 m5 m5 m5 m5
sided paralysis as the result of a stroke and assesses a pressure injury on the clie
nt‘s left h i p . W hich ofNtheRfollowing
I G is Bthe
.CmostM appropriate nursing diagnosis f Uo r
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
m 5 m 5 m 5 m 5 5
m 5
m m 5
m5 m5 m5 m
5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
t Sh i s cNl i e nTt ?
m5 m5 m5 m5 O
m5 m5 m5 m5
a. Impaired physical mobility related to decrease in muscle control (left-sided
m5 m5 m5 m5 m5 m5 m5 m5 m5
paralysis)
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge ab
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
out protecting tissue integrity
m5 m5 m5
c. Impaired skin integrity related to pressure over bony prominence (impai
m5 m5 m5 m5 m5 m5 m5 m5 m5
red circulation) m5
d. Ineffective tissue perfusion related to sedentary lifestyle m5 m5 m5 m5 m5 m5
ANS: m 5 C
The client‘s major problem is the impaired skin integrity as demonstrated by the presence
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m
of a pressure injury. The nurse is able to treat the cause of altered circulation and press
5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ure by frequently repositioning the client. Although left-
m5 m5 m5 m5 m5 m5 m5
sided weakness is a problem for the client, the nurse cannot treat the weakness. The ―ri
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
sk for‖ diagnosis is not appropriate for this client, who already has impaired tissue integri
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ty. The client does have ineffective tissue perfusion, but the impaired skin integrity diag
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
nosis indicates more clearly what the health problem is.
m5 m5 m5 m5 m5 m5 m5 m5
DIF: Cognitive Level: Application m5 m5 TOP: m 5 Nursing Process: Diagnosis m5 m5
6. The nurse caring for a client with an infection has a nursing diagnosis of deficien
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
t fluid volume related to excessive diaphoresis. Which of the following is an appro
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
priate client outcome? m5 m5
a. Client has a balanced intake and output.
m5 m5 m5 m5 m5 m5
b. Client‘s bedding is changed when it becomes damp.
m5 m5 m5 m5 m5 m5 m5
NURSINGTB.COM
, Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
c. Client understands the need for increased fluid intake.
m5 m5 m5 m5 m5 m5 m5
d. Client‘s skin remains cool and dry throughout hospitalization.
m5 m5 m5 m5 m5 m5 m5
ANS: m 5 A
This statement gives measurable data showing resolution of the problem of deficient flui
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
d volume that was identified in the nursing diagnosis statement. The other statements wou
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ld not indicate that the problem of deficient fluid volume was resolved.
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
DIF: Cognitive Level: Application m5 m5 TOP: m 5 Nursing Process: Planning m5 m5
7. Which of the following represents a nursing activity that is carried out during the evalu
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ation phase of the nursing process?
m5 m5 m5 m5 m5
a. Determining if interventions have been effective in meeting client outcomes
m5 m5 m5 m5 m5 m5 m5 m5 m5
b. Documenting the nursing care plan in the progress notes in the medical record
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
c. Deciding whether the client‘s health problems have been completely resolved
m5 m5 m5 m5 m5 m5 m5 m5 m5
d. Asking the client to evaluate whether the nursing care provided was satisfactory
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
ANS: m 5 A
Evaluation consists of determining whether the desired client outcomes have been met a
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
nd whether the nursing interventions were appropriate. The other responses do not describ
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
e the evaluation phase.
m5 m5 m5
DIF: Cognitive Level: Comprehension m5 m5 TOP: m 5 Nursing Process: Evaluationm5 m5
8. Which of the following would the nurse perform during the assessment phase of the nu
m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5 m5
rsing process? m5
a. Obtains data with which to diagnose client problems
m5 m5 m5 m5 m5 m5 m5
b. Uses client data to develoNp p R
m5 ri o riIt y nGursB
in.
m5gCdiagMnoses m5 m5 m5 m5 m 5 m5
m5 m5 m5
c. Teaches interventions to relieve client health problems
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d. Assists the client to identify realistic outcomes to health problems
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ANS: m 5 A
During the assessment phase, the nurse gathers information about the client. The other r
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esponses are examples of the intervention, diagnosis, and planning phases of the nursing
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process.
DIF: Cognitive Level: Knowledge m5 m5 TOP: m 5 Nursing Process: Assessmentm5 m5
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: m 5 C
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that descr
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ibes a client‘s response to a health problem that can be treated by nursing. The use of
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5a medical diagnosis (as in the responses beginning ―Altered tissue perfusion‖ and ―Alt
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ered urinary elimination‖) is not appropriate. The response beginning ―Risk for impaire
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d tissue integrity‖ uses the defining characteristics as the etiology.
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DIF: Cognitive Level: Comprehension m5 m5 TOP: m 5 Nursing Process: Diagnosis m5 m5
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