Lewis: Medical-Surgical Nursing, 10th
Edition
MULTIPLE
CHOICE
1. The nurse completes an admission database and explains that the plan of care and discharge
goals will be developed with the patient’s input. The patient states, “How is this different
fromwhat the doctor does?” Which response would be most appropriate for the nurse to
make?
a. “The role of the nurse is to administer medications and other treatments
prescribedby your doctor.”
b. “The nurse’s job is to help the doctor by collecting information and
communicating any problems that occur.”
c. “Nurses perform many of the same procedures as the doctor, but nurses are
withthe patients for a longer time than the doctor.”
d. “In addition to caring for you while you are sick, the nurses will assist you to
develop an individualized plan to maintain your health.”
ANS: D
This response is consistent with the American Nurses Association (ANA) definition of
nursing, which describes the role of nurses in promoting health. The other responses
describesome of the dependent and collaborative functions of the nursing role but do not
accurately describe the nurse’s role in the health care system.
DIF: Cognitive Level: Understand (comprehension) REF: 3
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care
Environment
2. The nurse describes to a student nurse how to use evidence-based practice guidelines
whencaring for patients. Which statement, if made by the nurse, would be the most
accurate?
a. “Inferences from clinical research studies are used as a guide.”
b. “Patient care is based on clinical judgment, experience, and traditions.”
c. “Data are evaluated to show that the patient outcomes are consistently met.”
d. “Recommendations are based on research, clinical expertise, and
patientpreferences.”
, ANS: D
Evidence-based practice (EBP) is the use of the best research-based evidence combined with
clinician expertise. Clinical judgment based on the nurse’s clinical experience is part of EBP,
but clinical decision making should also incorporate current research and research-based
guidelines. Evaluation of patient outcomes is important, but interventions should be based
onresearch from randomized control studies with a large number of subjects.
DIF: Cognitive Level: Remember (knowledge) REF: 15
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
3. The nurse teaches a student nurse about how to apply the nursing process when
providingpatient care. Which statement, if made by the student nurse, indicates that
teaching was successful?
a. “The nursing process is a scientific-based method of diagnosing the
patient’shealth care problems.”
b. “The nursing process is a problem-solving tool used to identify and treat patients’
, health care needs.”
c. “The nursing process is used primarily to explain nursing interventions to
otherhealth care professionals.”
d. “The nursing process is based on nursing theory that incorporates
thebiopsychosocial nature of humans.”
ANS: B
The nursing process is a problem-solving approach to the identification and treatment of
patients’ problems. Diagnosis is only one phase of the nursing process. The primary use of
thenursing process is in patient care, not to establish nursing theory or explain nursing
interventions to other health care professionals.
DIF: Cognitive Level: Understand (comprehension) REF: 5
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care
Environment
4. A patient has been admitted to the hospital for surgery and tells the nurse, “I do not feel
comfortable leaving my 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 call the children to ensure that they are doing well.
c. Gather more data about the patient’s feelings about the child-care arrangements.
d. Call the patient’s parents to determine whether adequate child care is
beingprovided.
ANS: C
Because 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
interventioncan be chosen.
DIF: Cognitive Level: Apply (application) REF: 6
OBJ: Special Questions: Prioritization TOP: Nursing Process:
AssessmentMSC: NCLEX: Psychosocial Integrity
5. A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer
on the left hip. Which 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