TESTBANK
w
,Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada Lewis:
w w w w w w w w w
Medical-Surgical Nursing in Canada, 4th Canadian Edition
w w w w w w w
MULTIPLE CHOICE w
1. When caring for clients using evidence-informed practice, which of the following does the
w w w w w w w w w w w w
nurse use?
w w
a. Clinical judgement based on experience w w w w
b. Evidence from a clinical research study w w w w w
c. The best available evidence to guide clinical expertise
w w w w w w w
d. Evaluation of data showing that the client outcomes are met w w w w w w w w w
ANS: C w
Evidence-informed nursing practice is a continuous interactive process involving the explicit, w w w w w w w w w w
conscientious, and judicious consideration of the best available evidence to provide care. Four
w w w w w w w w w w w w w
primary elements are: (a) clinical state, setting, and circumstances; (b) client preferences and
w w w w w w w w w w w w w
actions; (c) best research evidence; and (d) health care resources. Clinical judgement based on the
w w w w w w w w w w w w w w w
nurse’s clinical experience is part of EIP, but clinical decision making also should incorporate
w w w w w w w w w w w w w w
current research and research-based guidelines. Evidence from one clinical research study does
w w w w w w w w w w w w
not provide an adequate substantiation for interventions. Evaluation of client outcomes is
w w w w w w w w w w w w
important, but interventions should be based on research from randomized control studies with
w w w w w w w w w w w w w
a large number of subjects.
w w w w w
DIF: Cognitive Level: Comprehension w w TOP: Nursing Process: Planning w w w
2. Which of the following best e xpl ai n s th e nu rse s ’ pri m ary use of the nursing process when
N R I G B.C M
w w w w w w w w w w w
providing care to clients?
w
USNT O w w w
w w w
a. To explain nursing interventions to other health care professionals
w w w w w w w w
b. As a problem-solving tool to identify and treat clients’ health care needs
w w w w w w w w w w w
c. As a scientific-based process of diagnosing the client’s health care problems
w w w w w w w w w w
d. To establish nursing theory that incorporates the biopsychosocial nature of humans
w w w w w w w w w w
ANS: B w
The nursing process is an assertive problem-solving approach to the identification and treatment
w w w w w w w w w w w w
of clients’ problems. Diagnosis is only one phase of the nursing process. The primary use of the
w w w w w w w w w w w w w w w w w
nursing process is in client care, not to establish nursing theory or explain nursing interventions
w w w w w w w w w w w w w w w
to other health care professionals.
w w w w w
DIF: Cognitive Level: Comprehension w w TOP: Nursing Process: Implementationw w w
3. The nurse is caring for a critically ill client in the intensive care unit and plans an every 2-hour
w w w w w w w w w w w w w w w w w w
turning schedule to prevent skin breakdown. Which type of nursing function is demonstrated
w w w w w w w w w w w w w
with this turning schedule?
w w w w
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: D w
, When implementing collaborative nursing actions, the nurse is responsible primarily for
w w w w w w w w w w
monitoring for complications of acute illness or providing care to prevent or treat
w w w w w w w w w w w w w
complications. Independent nursing actions are focused on health promotion, illness
w w w w w w w w w w
prevention, and client advocacy. A dependent action would require a physician order to
w w w w w w w w w w w w w
implement. Cooperative nursing functions are not described as one of the formal nursing
w w w w w w w w w w w w w
functions.
w
DIF: Cognitive Level: Application w w TOP: Nursing Process: Implementation w w w
4. The nurse is caring for a client who has been admitted to the hospital for surgery and tells the
w w w w w w w w w w w w w w w w w w
nurse, “I do not feel right about leaving my children with my neighbour.” Which action should
w w w w w w w w w w w w w w w w
the nurse take next?
w w w w
a. Reassure the client that these feelings are common for parents. w w w w w w w w w
b. Have the client call the children to ensure that they are doing well.
w w w w w w w w w w w w
c. Call the neighbour to determine whether adequate childcare is being provided.
w w w w w w w w w w
d. Gather more data about the client’s feelings about the childcare arrangements.
w w w w w w w w w w
ANS: D w
Since a complete assessment is necessary in order to identify a problem and choose an
w w w w w w w w w w w w w w
appropriate intervention, the nurse’s first action should be to obtain more information. The
w w w w w w w w w w w w w
other actions may be appropriate, but more assessment is needed before the best intervention can
w w w w w w w w w w w w w w w
be chosen.
w w
DIF: Cognitive Level: Application w w TOP: Nursing Process: Assessment w w w
5. The nurse is caring for a client who has left-sided paralysis as the result of a stroke and
w w w w w w w w w w w w w w w w w
assesses a pressure injury on the client’s left hip. Which of the following is the most
No R
r tIS
hGi sBc.C MTt? O
w w w w w w w w w w w w w w w w
appropriate nursing diagnosis fU
w Nlien w w w
w
w
w w w
w
w
a. Impaired physical mobility related to decrease in muscle control (left-sided
w w w w w w w w w
paralysis)
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge about
w w w w w w w w w w
protecting tissue integrity
w w w
c. Impaired skin integrity related to pressure over bony prominence (impaired
w w w w w w w w w
circulation)
w
d. Ineffective tissue perfusion related to sedentary lifestyle w w w w w w
ANS: C w
The client’s major problem is the impaired skin integrity as demonstrated by the presence of a
w w w w w w w w w w w w w w w
pressure injury. The nurse is able to treat the cause of altered circulation and pressure by
w w w w w w w w w w w w w w w w
frequently repositioning the client. Although left-sided weakness is a problem for the client, the
w w w w w w w w w w w w w w
nurse cannot treat the weakness. The “risk for” diagnosis is not appropriate for this client, who
w w w w w w w w w w w w w w w w
already has impaired tissue integrity. The client does have ineffective tissue perfusion, but the
w w w w w w w w w w w w w w
impaired skin integrity diagnosis indicates more clearly what the health problem is.
w w w w w w w w w w w w
DIF: Cognitive Level: Application w w TOP: Nursing Process: Diagnosis w w w
6. The nurse caring for a client with an infection has a nursing diagnosis of deficient fluid
w w w w w w w w w w w w w w w
volume related to excessive diaphoresis. Which of the following is an appropriate client
w w w w w w w w w w w w w
outcome?
w
a. Client has a balanced intake and output. w w w w w w
b. Client’s bedding is changed when it becomes damp. w w w w w w w
, c. Client understands the need for increased fluid intake.
w w w w w w w
d. Client’s skin remains cool and dry throughout hospitalization.
w w w w w w w
ANS: A w
This statement gives measurable data showing resolution of the problem of deficient fluid
w w w w w w w w w w w w
volume that was identified in the nursing diagnosis statement. The other statements would not
w w w w w w w w w w w w w w
indicate that the problem of deficient fluid volume was resolved.
w w w w w w w w w w
DIF: Cognitive Level: Application w w TOP: Nursing Process: Planning w w w
7. Which of the following represents a nursing activity that is carried out during the evaluation
w w w w w w w w w w w w w w
wphase of the nursing process?
w w w w
a. Determining if interventions have been effective in meeting client outcomes w w w w w w w w w
b. Documenting the nursing care plan in the progress notes in the medical record w w w w w w w w w w w w
c. Deciding whether the client’s health problems have been completely resolved
w w w w w w w w w
d. Asking the client to evaluate whether the nursing care provided was satisfactory
w w w w w w w w w w w
ANS: A w
Evaluation consists of determining whether the desired client outcomes have been met and whether
w w w w w w w w w w w w w
the nursing interventions were appropriate. The other responses do not describe the evaluation phase.
w w w w w w w w w w w w w w
DIF: Cognitive Level: Comprehension w w TOP: Nursing Process: Evaluation w w w
8. Which of the following would the nurse perform during the assessment phase of the nursing
w w w w w w w w w w w w w w
wprocess?
a. Obtains data with which to diagnose client problems w w w w w w w
b. Uses client data to develoNp p R
r ioriIty nGursiBng.dCiagM
noses
USNclient
T health problems
w w w w w w
c. Teaches interventions to relieve w w w
w w
w
w
w w
d. Assists the client to identify realistic outcomes to health problems
w w w w w w w w w
ANS: A w
During the assessment phase, the nurse gathers information about the client. The other
w w w w w w w w w w w w
responses are examples of the intervention, diagnosis, and planning phases of the nursing
w w w w w w w w w w w w w
process.
w
DIF: Cognitive Level: Knowledge w w TOP: Nursing Process: Assessment w w w
9. Which of the following is an example of a correctly written nursing diagnosis statement?
w w w w w w w w w w w w w
a. Altered tissue perfusion related to heart failure w w w w w w
b. Risk for impaired tissue integrity related to sacral redness
w w w w w w w w
c. Ineffective coping related to insufficient sense of control. w w w w w w w
d. Altered urinary elimination related to urinary tract infection
w w w w w w w
ANS: C w
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes a
w w w w w w w w w w w w w
client’s response to a health problem that can be treated by nursing. The use of a medical
w w w w w w w w w w w w w w w w w
diagnosis (as in the responses beginning “Altered tissue perfusion” and “Altered urinary
w w w w w w w w w w w w
elimination”) is not appropriate. The response beginning “Risk for impaired tissue integrity”
w w w w w w w w w w w w
uses the defining characteristics as the etiology.
w w w w w w w
DIF: Cognitive Level: Comprehension w w TOP: Nursing Process: Diagnosis w w w
w
,Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada Lewis:
w w w w w w w w w
Medical-Surgical Nursing in Canada, 4th Canadian Edition
w w w w w w w
MULTIPLE CHOICE w
1. When caring for clients using evidence-informed practice, which of the following does the
w w w w w w w w w w w w
nurse use?
w w
a. Clinical judgement based on experience w w w w
b. Evidence from a clinical research study w w w w w
c. The best available evidence to guide clinical expertise
w w w w w w w
d. Evaluation of data showing that the client outcomes are met w w w w w w w w w
ANS: C w
Evidence-informed nursing practice is a continuous interactive process involving the explicit, w w w w w w w w w w
conscientious, and judicious consideration of the best available evidence to provide care. Four
w w w w w w w w w w w w w
primary elements are: (a) clinical state, setting, and circumstances; (b) client preferences and
w w w w w w w w w w w w w
actions; (c) best research evidence; and (d) health care resources. Clinical judgement based on the
w w w w w w w w w w w w w w w
nurse’s clinical experience is part of EIP, but clinical decision making also should incorporate
w w w w w w w w w w w w w w
current research and research-based guidelines. Evidence from one clinical research study does
w w w w w w w w w w w w
not provide an adequate substantiation for interventions. Evaluation of client outcomes is
w w w w w w w w w w w w
important, but interventions should be based on research from randomized control studies with
w w w w w w w w w w w w w
a large number of subjects.
w w w w w
DIF: Cognitive Level: Comprehension w w TOP: Nursing Process: Planning w w w
2. Which of the following best e xpl ai n s th e nu rse s ’ pri m ary use of the nursing process when
N R I G B.C M
w w w w w w w w w w w
providing care to clients?
w
USNT O w w w
w w w
a. To explain nursing interventions to other health care professionals
w w w w w w w w
b. As a problem-solving tool to identify and treat clients’ health care needs
w w w w w w w w w w w
c. As a scientific-based process of diagnosing the client’s health care problems
w w w w w w w w w w
d. To establish nursing theory that incorporates the biopsychosocial nature of humans
w w w w w w w w w w
ANS: B w
The nursing process is an assertive problem-solving approach to the identification and treatment
w w w w w w w w w w w w
of clients’ problems. Diagnosis is only one phase of the nursing process. The primary use of the
w w w w w w w w w w w w w w w w w
nursing process is in client care, not to establish nursing theory or explain nursing interventions
w w w w w w w w w w w w w w w
to other health care professionals.
w w w w w
DIF: Cognitive Level: Comprehension w w TOP: Nursing Process: Implementationw w w
3. The nurse is caring for a critically ill client in the intensive care unit and plans an every 2-hour
w w w w w w w w w w w w w w w w w w
turning schedule to prevent skin breakdown. Which type of nursing function is demonstrated
w w w w w w w w w w w w w
with this turning schedule?
w w w w
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: D w
, When implementing collaborative nursing actions, the nurse is responsible primarily for
w w w w w w w w w w
monitoring for complications of acute illness or providing care to prevent or treat
w w w w w w w w w w w w w
complications. Independent nursing actions are focused on health promotion, illness
w w w w w w w w w w
prevention, and client advocacy. A dependent action would require a physician order to
w w w w w w w w w w w w w
implement. Cooperative nursing functions are not described as one of the formal nursing
w w w w w w w w w w w w w
functions.
w
DIF: Cognitive Level: Application w w TOP: Nursing Process: Implementation w w w
4. The nurse is caring for a client who has been admitted to the hospital for surgery and tells the
w w w w w w w w w w w w w w w w w w
nurse, “I do not feel right about leaving my children with my neighbour.” Which action should
w w w w w w w w w w w w w w w w
the nurse take next?
w w w w
a. Reassure the client that these feelings are common for parents. w w w w w w w w w
b. Have the client call the children to ensure that they are doing well.
w w w w w w w w w w w w
c. Call the neighbour to determine whether adequate childcare is being provided.
w w w w w w w w w w
d. Gather more data about the client’s feelings about the childcare arrangements.
w w w w w w w w w w
ANS: D w
Since a complete assessment is necessary in order to identify a problem and choose an
w w w w w w w w w w w w w w
appropriate intervention, the nurse’s first action should be to obtain more information. The
w w w w w w w w w w w w w
other actions may be appropriate, but more assessment is needed before the best intervention can
w w w w w w w w w w w w w w w
be chosen.
w w
DIF: Cognitive Level: Application w w TOP: Nursing Process: Assessment w w w
5. The nurse is caring for a client who has left-sided paralysis as the result of a stroke and
w w w w w w w w w w w w w w w w w
assesses a pressure injury on the client’s left hip. Which of the following is the most
No R
r tIS
hGi sBc.C MTt? O
w w w w w w w w w w w w w w w w
appropriate nursing diagnosis fU
w Nlien w w w
w
w
w w w
w
w
a. Impaired physical mobility related to decrease in muscle control (left-sided
w w w w w w w w w
paralysis)
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge about
w w w w w w w w w w
protecting tissue integrity
w w w
c. Impaired skin integrity related to pressure over bony prominence (impaired
w w w w w w w w w
circulation)
w
d. Ineffective tissue perfusion related to sedentary lifestyle w w w w w w
ANS: C w
The client’s major problem is the impaired skin integrity as demonstrated by the presence of a
w w w w w w w w w w w w w w w
pressure injury. The nurse is able to treat the cause of altered circulation and pressure by
w w w w w w w w w w w w w w w w
frequently repositioning the client. Although left-sided weakness is a problem for the client, the
w w w w w w w w w w w w w w
nurse cannot treat the weakness. The “risk for” diagnosis is not appropriate for this client, who
w w w w w w w w w w w w w w w w
already has impaired tissue integrity. The client does have ineffective tissue perfusion, but the
w w w w w w w w w w w w w w
impaired skin integrity diagnosis indicates more clearly what the health problem is.
w w w w w w w w w w w w
DIF: Cognitive Level: Application w w TOP: Nursing Process: Diagnosis w w w
6. The nurse caring for a client with an infection has a nursing diagnosis of deficient fluid
w w w w w w w w w w w w w w w
volume related to excessive diaphoresis. Which of the following is an appropriate client
w w w w w w w w w w w w w
outcome?
w
a. Client has a balanced intake and output. w w w w w w
b. Client’s bedding is changed when it becomes damp. w w w w w w w
, c. Client understands the need for increased fluid intake.
w w w w w w w
d. Client’s skin remains cool and dry throughout hospitalization.
w w w w w w w
ANS: A w
This statement gives measurable data showing resolution of the problem of deficient fluid
w w w w w w w w w w w w
volume that was identified in the nursing diagnosis statement. The other statements would not
w w w w w w w w w w w w w w
indicate that the problem of deficient fluid volume was resolved.
w w w w w w w w w w
DIF: Cognitive Level: Application w w TOP: Nursing Process: Planning w w w
7. Which of the following represents a nursing activity that is carried out during the evaluation
w w w w w w w w w w w w w w
wphase of the nursing process?
w w w w
a. Determining if interventions have been effective in meeting client outcomes w w w w w w w w w
b. Documenting the nursing care plan in the progress notes in the medical record w w w w w w w w w w w w
c. Deciding whether the client’s health problems have been completely resolved
w w w w w w w w w
d. Asking the client to evaluate whether the nursing care provided was satisfactory
w w w w w w w w w w w
ANS: A w
Evaluation consists of determining whether the desired client outcomes have been met and whether
w w w w w w w w w w w w w
the nursing interventions were appropriate. The other responses do not describe the evaluation phase.
w w w w w w w w w w w w w w
DIF: Cognitive Level: Comprehension w w TOP: Nursing Process: Evaluation w w w
8. Which of the following would the nurse perform during the assessment phase of the nursing
w w w w w w w w w w w w w w
wprocess?
a. Obtains data with which to diagnose client problems w w w w w w w
b. Uses client data to develoNp p R
r ioriIty nGursiBng.dCiagM
noses
USNclient
T health problems
w w w w w w
c. Teaches interventions to relieve w w w
w w
w
w
w w
d. Assists the client to identify realistic outcomes to health problems
w w w w w w w w w
ANS: A w
During the assessment phase, the nurse gathers information about the client. The other
w w w w w w w w w w w w
responses are examples of the intervention, diagnosis, and planning phases of the nursing
w w w w w w w w w w w w w
process.
w
DIF: Cognitive Level: Knowledge w w TOP: Nursing Process: Assessment w w w
9. Which of the following is an example of a correctly written nursing diagnosis statement?
w w w w w w w w w w w w w
a. Altered tissue perfusion related to heart failure w w w w w w
b. Risk for impaired tissue integrity related to sacral redness
w w w w w w w w
c. Ineffective coping related to insufficient sense of control. w w w w w w w
d. Altered urinary elimination related to urinary tract infection
w w w w w w w
ANS: C w
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes a
w w w w w w w w w w w w w
client’s response to a health problem that can be treated by nursing. The use of a medical
w w w w w w w w w w w w w w w w w
diagnosis (as in the responses beginning “Altered tissue perfusion” and “Altered urinary
w w w w w w w w w w w w
elimination”) is not appropriate. The response beginning “Risk for impaired tissue integrity”
w w w w w w w w w w w w
uses the defining characteristics as the etiology.
w w w w w w w
DIF: Cognitive Level: Comprehension w w TOP: Nursing Process: Diagnosis w w w
