MedicalSurgicalNursing10th-Edition-
LewisTest-Bank.
h4
,Chapter01:ProfessionalNursingPracticeLewis:
h
4 h
4 h
4 h
4 h4
Medical-SurgicalNursing,10thEdition a
b a
b
MULTIPLECHOICE
1. Thenursecompletesanadmissiondatabaseandexplainsthattheplanofcareanddischargegoals h 4
h willbedevelopedwiththepatient’sinput.Thepatient states,“Howisthisdifferentfromwhatthe
4 ba ba h4
doctordoes?”Whichresponsewouldbemostappropriateforthenursetomake?
h4 h4 h4 h
4
a. “Theroleofthenurseistoadministermedicationsand othertreatmentsprescribedby ba ba h4
yourdoctor.” h4
b. “Thenurse’sjobistohelpthedoctorbycollectinginformationand h4 ba
communicatinganyproblemsthatoccur.”
h4
c. “Nursesperformmanyofthesameproceduresasthedoctor, but nurses arewiththe ba h4 ba ba ba h4
patientsforalongertimethanthedoctor.”
h4
d. “Inadditiontocaringforyouwhile youaresick,thenurseswillassist youto ba h4 ba ba
developanindividualizedplantomaintainyourhealth.”
h4
ANS: D h 4
ThisresponseisconsistentwiththeAmericanNursesAssociation(ANA)definitionofnursing, h4 h4 h4 h4
which describestheroleofnursesinpromotinghealth.Theotherresponsesdescribe someofthe
h4 ba h4 ba
dependent andcollaborative functionsofthenursing role butdonotaccuratelydescribethenurse’s
h4 ba h4
h roleinthehealthcaresystem.
4
DIF: CognitiveLevel:Understand(comprehension) ba ba REF: 3
TOP: NursingProcess: Implementation MSC: h4 h 4 NCLEX:SafeandEffectiveCareEnvironment ba
2. Thenursedescribestoastudentnursehowtouseevidence-basedpracticeguidelineswhen
h 4 caringforpatients.Whichstatement,ifmadebythenurse,wouldbe themost accurate? h4 h4 h4 h4 h4 h4 h4
a. “Inferencesfrom clinicalresearchstudiesareused asa guide.” ba h4 ba h4 ba ba
b. “Patientcareisbasedonclinicaljudgment,experience, and traditions.” h4 ba
c. “Data are evaluatedtoshowthatthepatientoutcomesareconsistentlymet.”
ba h 4 ba
d. “Recommendationsarebasedonresearch,clinicalexpertise,andpatient ba ba ba ba ba
preferences.”
h4
ANS: D h 4
Evidence-basedpractice(EBP)istheuseofthebestresearch-basedevidencecombinedwith h4
hclinicianexpertise.Clinicaljudgmentbased onthenurse’sclinicalexperienceispartofEBP,but
4 ba ba ba ba h4
clinical decisionmakingshouldalsoincorporate currentresearchandresearch-based guidelines.
h4 ba ba ba h 4
h Evaluationofpatientoutcomesisimportant,but interventionsshouldbebasedonresearchfrom
4 ba ba ba ba h4
randomizedcontrolstudieswithalargenumberofsubjects.
h4 ba
DIF: CognitiveLevel:Remember(knowledge) ba REF: 15
TOP: NursingProcess: Planning MSC: ba h4 h 4 NCLEX:SafeandEffectiveCareEnvironment ba
3. Thenurseteachesastudentnurseabouthowtoapplythenursingprocesswhenproviding ba ba
patientcare. Whichstatement, ifmadebythestudentnurse,indicatesthatteachingwas
h4 h4 h4
successful?
h4
a. “Thenursingprocessisascientific-basedmethodofdiagnosingthepatient’s ba ba ba
healthcareproblems.”
h4
b. “Thenursing processisaproblem-solving toolused toidentifyandtreat patients’
ba ba h4 ba h4 ba ba
, healthcareneeds.” ba
c. “Thenursingprocessisusedprimarilytoexplainnursinginterventionstoother
ba ba ba ba ba
healthcareprofessionals.”
h 4
d. “Thenursingprocessisbasedonnursingtheorythatincorporatesthe
ba ba ba ba ba
biopsychosocialnatureofhumans.”
h4
ANS: B h 4
Thenursingprocessisaproblem-solvingapproachtotheidentificationandtreatmentofpatients’ ba h 4
h problems.Diagnosisisonlyonephaseofthenursingprocess.Theprimaryuseofthe
4 h4 ba
nursingprocess isinpatientcare,
h4 h4
nottoestablishnursingtheoryorexplainnursing interventionstootherhealthcare professionals.
h4 ba h 4
DIF: CognitiveLevel:Understand(comprehension) ba REF: 5
TOP: NursingProcess: Implementation MSC: h4 h 4 NCLEX:SafeandEffectiveCareEnvironment ba
4. Apatienthasbeenadmittedtothehospitalforsurgeryandtellsthenurse,“Idonotfeel ba ba h 4 h 4
h 4 comfortableleavingmychildrenwithmyparents.”Whichactionshouldthenursetakenext?
ba ba ba ba ba ba
a. Reassurethepatient that thesefeelingsarecommonforparents. ba h4
b. Havethepatientcallthe childrentoensurethat theyaredoingwell. h4 ba
c. Gathermoredataabout thepatient’sfeelingsaboutthechild-carearrangements. ba ba
d. Callthepatient’sparentstodeterminewhetheradequatechildcareisbeing
ba ba
provided.
h4
ANS: C h 4
Becauseacompleteassessmentisnecessaryinordertoidentifyaproblemandchoosean ba ba h 4
h appropriateintervention,thenurse’sfirstactionshould be toobtainmoreinformation.Theother
4 h4 h4 h4 h4 ba h4
actionsmaybeappropriate,butmoreassessmentisneeded beforethebestinterventioncanbe
h4 ba ba h4
chosen.
h4
DIF: CognitiveLevel:Apply(application) REF: 6
OBJ: SpecialQuestions:Prioritization h4 h4 TOP: NursingProcess:Assessment
h4 ba
MSC: NCLEX:Psychosocial Integrity
h4 h 4 h4 h4
5. Apatient whoisparalyzed ontheleftsideofthebodyafterastrokedevelops a pressure ulceronthe
ba ba ba h4 ba ba ba h4
h4 lefthip.Which nursingdiagnosisismostappropriate?
h4 ba h4 h4
a. Impairedphysicalmobilityrelatedtoleft-sidedparalysis
b. Risk forimpaired tissueintegrityrelatedtoleft-sidedweakness
ba h 4
c. Impairedskinintegrityrelated toaltered circulationandpressure ba ba h4
d. Ineffectivetissueperfusionrelatedtoinabilitytomoveindependently
ANS: C h 4
Thepatient’smajorproblemistheimpairedskinintegrityasdemonstrated bythepresence ofa h4 ba
h pressureulcer.Thenurseisabletotreatthecauseofalteredcirculationandpressurebyfrequently
4 ba h 4
h 4repositioningthepatient.Althoughleft-sidedweaknessisaproblem forthepatient,
h 4 ba ba ba ba
thenursecannot treattheweakness.The“riskfor”diagnosisisnot appropriateforthispatient,
h4 h4 ba ba
whoalreadyhas impairedtissueintegrity.The patient doeshave ineffectivetissue perfusion,
h4 h4 h4 ba
but theimpaired skin integritydiagnosisindicatesmoreclearlywhatthehealthproblemis.
h4 ba h 4
DIF: CognitiveLevel:Apply(application) ba REF: 7
TOP: NursingProcess: Diagnosis h4 MSC: h NCLEX:PhysiologicalIntegrity
4
, 6. Apatientwithabacterialinfectionhas a nursingdiagnosisof deficient fluidvolume relatedto
ba ba h4 ba ba ba ba ba ba
h4 excessivediaphoresis.Which outcome would the nurse recognize asappropriate forthispatient? h4 ba
a. Patienthasa balancedintakeand output. ba ba h4
b. Patient’sbeddingischanged when itbecomes damp. ba ba ba h4
c. Patientunderstandstheneedforincreased fluid intake. ba ba
d. Patient’sskin remainscooland drythroughout hospitalization.
ba ba ba h4
ANS: A h 4
Thisstatementgivesmeasurabledatashowingresolutionoftheproblemofdeficientfluidvolume
ba
thatwasidentified inthenursingdiagnosisstatement.Theotherstatementswouldnot indicate that
h4 ba ba ba ba h4
theproblemofdeficientfluidvolumewasresolved.
h4
DIF: CognitiveLevel:Apply(application) ba REF: 7
TOP: NursingProcess: Planning ba h4 MSC: hNCLEX:PhysiologicalIntegrity
4
7. Anurseasks thepatientifpainwasrelievedafterreceivingmedication.Whatisthe purposeofthe
ba ba ba ba ba h4
h4 evaluationphaseofthenursingprocess? ba
a. Todetermineifinterventionshavebeeneffectiveinmeetingpatientoutcomes ba h4
b. Todocumentthe nursingcareplan in theprogress notesofthemedicalrecord ba ba ba h4
c. Todecidewhetherthepatient’shealthproblemshavebeencompletelyresolved h4
d. Toestablishifthepatientagreesthatthenursingcareprovidedwas satisfactory ba ba h 4 h 4
ANS: A h 4
Evaluation consists of determining whether the desired patient outcomes have been met and
h4 h4 h4 h4 h4 h4 h4 h4 h4 h4 h4 h4
whether the nursing interventions were appropriate. The other responses do not describe the
h4 h4 h4 h4 h4 h4 h4 h4 h4 h4 h4 h4 h4
evaluationphase.
h4
DIF: CognitiveLevel: Understand(comprehension) REF: 5 h4
TOP: Nursing Process:Evaluation MSC: NCLEX:SafeandEffectiveCareEnvironment
ba h 4 ba
8. Thenurseinterviews apatientwhilecompletingthehealthhistoryandphysicalexamination.What ba ba ba ba h4
isthepurposeoftheassessmentphaseofthenursingprocess?
h4
a. Toteachinterventionsthatrelievehealthproblems ba
b. Tousepatientdatatoevaluatepatientcareoutcomes ba
c. Toobtaindatawithwhichtodiagnosepatientproblems ba
d. Tohelpthepatientidentifyrealisticoutcomesforhealthproblems
ANS: C h 4
Duringtheassessmentphase,thenursegathersinformationabout thepatienttodiagnosepatient
ba ba h4
problems.Theotherresponsesareexamplesoftheplanning,intervention,and evaluation phasesof
h4 h4 h4 h4 ba ba
thenursingprocess.
h4
DIF: CognitiveLevel: Understand(comprehension) REF: 5 h4
TOP: NursingProcess:Assessment MSC: NCLEX:SafeandEffectiveCareEnvironment
ba h 4 ba ba
9. Which nursingdiagnosisstatementiswrittencorrectly?
ba h4 ba
a. Altered tissue perfusionrelatedtoheart failure
ba ba h4 ba
b. Risk forimpairedtissueintegrityrelated tosacralredness
b h4 ba h4
c. Ineffectivecopingrelatedtoresponsetobiopsytestresults
d. Altered urinaryeliminationrelatedtourinarytractinfection
ba h4
LewisTest-Bank.
h4
,Chapter01:ProfessionalNursingPracticeLewis:
h
4 h
4 h
4 h
4 h4
Medical-SurgicalNursing,10thEdition a
b a
b
MULTIPLECHOICE
1. Thenursecompletesanadmissiondatabaseandexplainsthattheplanofcareanddischargegoals h 4
h willbedevelopedwiththepatient’sinput.Thepatient states,“Howisthisdifferentfromwhatthe
4 ba ba h4
doctordoes?”Whichresponsewouldbemostappropriateforthenursetomake?
h4 h4 h4 h
4
a. “Theroleofthenurseistoadministermedicationsand othertreatmentsprescribedby ba ba h4
yourdoctor.” h4
b. “Thenurse’sjobistohelpthedoctorbycollectinginformationand h4 ba
communicatinganyproblemsthatoccur.”
h4
c. “Nursesperformmanyofthesameproceduresasthedoctor, but nurses arewiththe ba h4 ba ba ba h4
patientsforalongertimethanthedoctor.”
h4
d. “Inadditiontocaringforyouwhile youaresick,thenurseswillassist youto ba h4 ba ba
developanindividualizedplantomaintainyourhealth.”
h4
ANS: D h 4
ThisresponseisconsistentwiththeAmericanNursesAssociation(ANA)definitionofnursing, h4 h4 h4 h4
which describestheroleofnursesinpromotinghealth.Theotherresponsesdescribe someofthe
h4 ba h4 ba
dependent andcollaborative functionsofthenursing role butdonotaccuratelydescribethenurse’s
h4 ba h4
h roleinthehealthcaresystem.
4
DIF: CognitiveLevel:Understand(comprehension) ba ba REF: 3
TOP: NursingProcess: Implementation MSC: h4 h 4 NCLEX:SafeandEffectiveCareEnvironment ba
2. Thenursedescribestoastudentnursehowtouseevidence-basedpracticeguidelineswhen
h 4 caringforpatients.Whichstatement,ifmadebythenurse,wouldbe themost accurate? h4 h4 h4 h4 h4 h4 h4
a. “Inferencesfrom clinicalresearchstudiesareused asa guide.” ba h4 ba h4 ba ba
b. “Patientcareisbasedonclinicaljudgment,experience, and traditions.” h4 ba
c. “Data are evaluatedtoshowthatthepatientoutcomesareconsistentlymet.”
ba h 4 ba
d. “Recommendationsarebasedonresearch,clinicalexpertise,andpatient ba ba ba ba ba
preferences.”
h4
ANS: D h 4
Evidence-basedpractice(EBP)istheuseofthebestresearch-basedevidencecombinedwith h4
hclinicianexpertise.Clinicaljudgmentbased onthenurse’sclinicalexperienceispartofEBP,but
4 ba ba ba ba h4
clinical decisionmakingshouldalsoincorporate currentresearchandresearch-based guidelines.
h4 ba ba ba h 4
h Evaluationofpatientoutcomesisimportant,but interventionsshouldbebasedonresearchfrom
4 ba ba ba ba h4
randomizedcontrolstudieswithalargenumberofsubjects.
h4 ba
DIF: CognitiveLevel:Remember(knowledge) ba REF: 15
TOP: NursingProcess: Planning MSC: ba h4 h 4 NCLEX:SafeandEffectiveCareEnvironment ba
3. Thenurseteachesastudentnurseabouthowtoapplythenursingprocesswhenproviding ba ba
patientcare. Whichstatement, ifmadebythestudentnurse,indicatesthatteachingwas
h4 h4 h4
successful?
h4
a. “Thenursingprocessisascientific-basedmethodofdiagnosingthepatient’s ba ba ba
healthcareproblems.”
h4
b. “Thenursing processisaproblem-solving toolused toidentifyandtreat patients’
ba ba h4 ba h4 ba ba
, healthcareneeds.” ba
c. “Thenursingprocessisusedprimarilytoexplainnursinginterventionstoother
ba ba ba ba ba
healthcareprofessionals.”
h 4
d. “Thenursingprocessisbasedonnursingtheorythatincorporatesthe
ba ba ba ba ba
biopsychosocialnatureofhumans.”
h4
ANS: B h 4
Thenursingprocessisaproblem-solvingapproachtotheidentificationandtreatmentofpatients’ ba h 4
h problems.Diagnosisisonlyonephaseofthenursingprocess.Theprimaryuseofthe
4 h4 ba
nursingprocess isinpatientcare,
h4 h4
nottoestablishnursingtheoryorexplainnursing interventionstootherhealthcare professionals.
h4 ba h 4
DIF: CognitiveLevel:Understand(comprehension) ba REF: 5
TOP: NursingProcess: Implementation MSC: h4 h 4 NCLEX:SafeandEffectiveCareEnvironment ba
4. Apatienthasbeenadmittedtothehospitalforsurgeryandtellsthenurse,“Idonotfeel ba ba h 4 h 4
h 4 comfortableleavingmychildrenwithmyparents.”Whichactionshouldthenursetakenext?
ba ba ba ba ba ba
a. Reassurethepatient that thesefeelingsarecommonforparents. ba h4
b. Havethepatientcallthe childrentoensurethat theyaredoingwell. h4 ba
c. Gathermoredataabout thepatient’sfeelingsaboutthechild-carearrangements. ba ba
d. Callthepatient’sparentstodeterminewhetheradequatechildcareisbeing
ba ba
provided.
h4
ANS: C h 4
Becauseacompleteassessmentisnecessaryinordertoidentifyaproblemandchoosean ba ba h 4
h appropriateintervention,thenurse’sfirstactionshould be toobtainmoreinformation.Theother
4 h4 h4 h4 h4 ba h4
actionsmaybeappropriate,butmoreassessmentisneeded beforethebestinterventioncanbe
h4 ba ba h4
chosen.
h4
DIF: CognitiveLevel:Apply(application) REF: 6
OBJ: SpecialQuestions:Prioritization h4 h4 TOP: NursingProcess:Assessment
h4 ba
MSC: NCLEX:Psychosocial Integrity
h4 h 4 h4 h4
5. Apatient whoisparalyzed ontheleftsideofthebodyafterastrokedevelops a pressure ulceronthe
ba ba ba h4 ba ba ba h4
h4 lefthip.Which nursingdiagnosisismostappropriate?
h4 ba h4 h4
a. Impairedphysicalmobilityrelatedtoleft-sidedparalysis
b. Risk forimpaired tissueintegrityrelatedtoleft-sidedweakness
ba h 4
c. Impairedskinintegrityrelated toaltered circulationandpressure ba ba h4
d. Ineffectivetissueperfusionrelatedtoinabilitytomoveindependently
ANS: C h 4
Thepatient’smajorproblemistheimpairedskinintegrityasdemonstrated bythepresence ofa h4 ba
h pressureulcer.Thenurseisabletotreatthecauseofalteredcirculationandpressurebyfrequently
4 ba h 4
h 4repositioningthepatient.Althoughleft-sidedweaknessisaproblem forthepatient,
h 4 ba ba ba ba
thenursecannot treattheweakness.The“riskfor”diagnosisisnot appropriateforthispatient,
h4 h4 ba ba
whoalreadyhas impairedtissueintegrity.The patient doeshave ineffectivetissue perfusion,
h4 h4 h4 ba
but theimpaired skin integritydiagnosisindicatesmoreclearlywhatthehealthproblemis.
h4 ba h 4
DIF: CognitiveLevel:Apply(application) ba REF: 7
TOP: NursingProcess: Diagnosis h4 MSC: h NCLEX:PhysiologicalIntegrity
4
, 6. Apatientwithabacterialinfectionhas a nursingdiagnosisof deficient fluidvolume relatedto
ba ba h4 ba ba ba ba ba ba
h4 excessivediaphoresis.Which outcome would the nurse recognize asappropriate forthispatient? h4 ba
a. Patienthasa balancedintakeand output. ba ba h4
b. Patient’sbeddingischanged when itbecomes damp. ba ba ba h4
c. Patientunderstandstheneedforincreased fluid intake. ba ba
d. Patient’sskin remainscooland drythroughout hospitalization.
ba ba ba h4
ANS: A h 4
Thisstatementgivesmeasurabledatashowingresolutionoftheproblemofdeficientfluidvolume
ba
thatwasidentified inthenursingdiagnosisstatement.Theotherstatementswouldnot indicate that
h4 ba ba ba ba h4
theproblemofdeficientfluidvolumewasresolved.
h4
DIF: CognitiveLevel:Apply(application) ba REF: 7
TOP: NursingProcess: Planning ba h4 MSC: hNCLEX:PhysiologicalIntegrity
4
7. Anurseasks thepatientifpainwasrelievedafterreceivingmedication.Whatisthe purposeofthe
ba ba ba ba ba h4
h4 evaluationphaseofthenursingprocess? ba
a. Todetermineifinterventionshavebeeneffectiveinmeetingpatientoutcomes ba h4
b. Todocumentthe nursingcareplan in theprogress notesofthemedicalrecord ba ba ba h4
c. Todecidewhetherthepatient’shealthproblemshavebeencompletelyresolved h4
d. Toestablishifthepatientagreesthatthenursingcareprovidedwas satisfactory ba ba h 4 h 4
ANS: A h 4
Evaluation consists of determining whether the desired patient outcomes have been met and
h4 h4 h4 h4 h4 h4 h4 h4 h4 h4 h4 h4
whether the nursing interventions were appropriate. The other responses do not describe the
h4 h4 h4 h4 h4 h4 h4 h4 h4 h4 h4 h4 h4
evaluationphase.
h4
DIF: CognitiveLevel: Understand(comprehension) REF: 5 h4
TOP: Nursing Process:Evaluation MSC: NCLEX:SafeandEffectiveCareEnvironment
ba h 4 ba
8. Thenurseinterviews apatientwhilecompletingthehealthhistoryandphysicalexamination.What ba ba ba ba h4
isthepurposeoftheassessmentphaseofthenursingprocess?
h4
a. Toteachinterventionsthatrelievehealthproblems ba
b. Tousepatientdatatoevaluatepatientcareoutcomes ba
c. Toobtaindatawithwhichtodiagnosepatientproblems ba
d. Tohelpthepatientidentifyrealisticoutcomesforhealthproblems
ANS: C h 4
Duringtheassessmentphase,thenursegathersinformationabout thepatienttodiagnosepatient
ba ba h4
problems.Theotherresponsesareexamplesoftheplanning,intervention,and evaluation phasesof
h4 h4 h4 h4 ba ba
thenursingprocess.
h4
DIF: CognitiveLevel: Understand(comprehension) REF: 5 h4
TOP: NursingProcess:Assessment MSC: NCLEX:SafeandEffectiveCareEnvironment
ba h 4 ba ba
9. Which nursingdiagnosisstatementiswrittencorrectly?
ba h4 ba
a. Altered tissue perfusionrelatedtoheart failure
ba ba h4 ba
b. Risk forimpairedtissueintegrityrelated tosacralredness
b h4 ba h4
c. Ineffectivecopingrelatedtoresponsetobiopsytestresults
d. Altered urinaryeliminationrelatedtourinarytractinfection
ba h4
