MedicalSurgicalNursing10th-Edition-
LewisTest-Bank.
r9
,Chapter01:ProfessionalNursingPracticeLewis:
r9 r9 r9 r9 r9
Medical-SurgicalNursing,10thEdition a
b a
b
MULTIPLECHOICE
1. Thenursecompletesanadmissiondatabaseandexplainsthattheplanofcareanddischargegoals r 9
r willbedevelopedwiththepatient’sinput.Thepatient states,“Howisthisdifferentfromwhatthe
9 ba ba r9
doctordoes?”Whichresponsewouldbemostappropriateforthenursetomake?
r9 r9 r9 r9
a. “Theroleofthenurseistoadministermedicationsand othertreatmentsprescribedby ba ba r9
yourdoctor.”r9
b. “Thenurse’sjobistohelpthedoctorbycollectinginformationand r9 ba
communicatinganyproblemsthatoccur.”
r9
c. “Nursesperformmanyofthesameproceduresasthedoctor, but nurses arewiththe ba r9 ba ba ba r9
patientsforalongertimethanthedoctor.”
r9
d. “Inadditiontocaringforyouwhile youaresick,thenurseswillassist youto
ba r9 ba ba
developanindividualizedplantomaintainyourhealth.”
r9
ANS: D r 9
ThisresponseisconsistentwiththeAmericanNursesAssociation(ANA)definitionofnursing, r9 r9 r9 r9
which describestheroleofnursesinpromotinghealth.Theotherresponsesdescribe someofthe
r9 ba r9 ba
dependent andcollaborative functionsofthenursing role butdonotaccuratelydescribethenurse’s
r9 ba r9
r roleinthehealthcaresystem.
9
DIF: CognitiveLevel:Understand(comprehension) REF: 3 ba ba
TOP: NursingProcess: Implementation MSC: NCLEX:SafeandEffectiveCareEnvironment r9 r 9 ba
2. Thenursedescribestoastudentnursehowtouseevidence-basedpracticeguidelineswhen
r 9 caringforpatients.Whichstatement,ifmadebythenurse,wouldbethemost accurate? r9 r9 r9 r9 r9 r9 r9
a. “Inferencesfrom clinicalresearchstudiesareusedasa guide.” ba r9 ba r9 ba ba
b. “Patientcareisbasedonclinicaljudgment,experience, and traditions.” r9 ba
c. “Data are evaluatedtoshowthatthepatientoutcomesareconsistentlymet.”
ba r 9 ba
d. “Recommendationsarebasedonresearch,clinicalexpertise,andpatient ba ba ba ba ba
preferences.”
r9
ANS: D r 9
Evidence-basedpractice(EBP)istheuseofthebestresearch-basedevidencecombinedwith r9
clinicianexpertise.Clinicaljudgmentbased onthenurse’sclinicalexperienceispartofEBP,but
r 9 ba ba ba ba r9
clinical decisionmakingshouldalsoincorporatecurrentresearchandresearch-based guidelines.
r9 ba ba ba r 9
r Evaluationof patientoutcomesisimportant,but interventionsshouldbebasedonresearchfrom
9 ba ba ba ba r9
randomized controlstudieswithalargenumberofsubjects.
r9 ba
DIF: CognitiveLevel:Remember(knowledge) ba REF: 15
TOP: NursingProcess:Planning MSC: ba r9 r 9 NCLEX:SafeandEffectiveCareEnvironment ba
3. Thenurseteachesastudentnurseabouthowtoapplythenursingprocesswhenproviding ba ba
patientcare. Whichstatement, ifmadebythestudentnurse,indicatesthatteachingwas
r9 r9 r9
successful?
r9
a. “Thenursingprocessisascientific-basedmethodofdiagnosingthepatient’s ba ba ba
healthcareproblems.”
r9
b. “Thenursing processisaproblem-solving toolused toidentifyandtreat patients’
ba ba r9 ba r9 ba ba
, healthcareneeds.” ba
c. “Thenursingprocessisusedprimarilytoexplainnursinginterventionstoother
ba ba ba ba ba
healthcareprofessionals.”
r 9
d. “Thenursingprocessisbasedonnursingtheorythatincorporatesthe
ba ba ba ba ba
biopsychosocialnatureofhumans.”
r9
ANS: B r 9
Thenursingprocessisaproblem-solvingapproachtotheidentificationandtreatmentofpatients’ ba r 9
r problems.Diagnosisisonlyonephaseofthenursingprocess.Theprimaryuseofthe
9 r9 ba
nursingprocess isinpatientcare,
r9 r9
nottoestablishnursingtheoryorexplainnursing interventionstootherhealthcare professionals.
r9 ba r 9
DIF: CognitiveLevel:Understand(comprehension) REF: 5 ba
TOP: NursingProcess: Implementation MSC: NCLEX:SafeandEffectiveCareEnvironment r9 r 9 ba
4. Apatienthasbeenadmittedtothehospitalforsurgeryandtellsthenurse,“Idonotfeel ba ba r 9 r 9
r 9 comfortableleavingmychildrenwithmyparents.”Whichactionshouldthenursetakenext?
ba ba ba ba ba ba
a. Reassurethepatient that thesefeelingsarecommonforparents. ba r9
b. Havethepatientcallthe childrentoensurethat theyaredoingwell. r9 ba
c. Gathermoredataabout thepatient’sfeelingsaboutthechild-carearrangements. ba ba
d. Callthepatient’sparentstodeterminewhetheradequatechildcareisbeing
ba ba
provided.
r9
ANS: C r 9
Becauseacompleteassessmentisnecessaryinordertoidentifyaproblemandchoosean ba ba r 9
r appropriateintervention,thenurse’sfirstactionshould be toobtainmoreinformation.Theother
9 r9 r9 r9 r9 ba r9
actionsmaybeappropriate,butmoreassessmentisneeded beforethebestinterventioncanbe
r9 ba ba r9
chosen.
r9
DIF: CognitiveLevel:Apply(application) REF: 6
OBJ: SpecialQuestions:Prioritization r9 r9 TOP: NursingProcess:Assessment
r9 ba
MSC: NCLEX:PsychosocialIntegrity
r9 r 9 r9 r9
5. Apatient whoisparalyzed ontheleftsideofthebodyafterastrokedevelops a pressure ulceronthe
ba ba ba r9 ba ba ba r9
r9 lefthip.Which nursingdiagnosisismostappropriate?
r9 ba r9 r9
a. Impairedphysicalmobilityrelatedtoleft-sidedparalysis
b. Risk forimpaired tissueintegrityrelatedtoleft-sidedweakness
ba r 9
c. Impairedskinintegrityrelated toaltered circulationandpressure ba ba r9
d. Ineffectivetissueperfusionrelatedtoinabilitytomoveindependently
ANS: C r 9
Thepatient’smajorproblemistheimpairedskinintegrityasdemonstrated bythepresence ofa r9 ba
r pressureulcer.Thenurseisabletotreatthecauseofalteredcirculationandpressurebyfrequently
9 ba r 9
r repositioningthepatient.Althoughleft-sidedweaknessisaproblem forthepatient,
9 r 9 ba ba ba ba
thenursecannot treattheweakness.The“riskfor”diagnosisisnot appropriateforthispatient,
r9 r9 ba ba
whoalreadyhas impairedtissueintegrity.The patient doeshave ineffectivetissue perfusion,
r9 r9 r9 ba
but theimpaired skin integritydiagnosisindicatesmoreclearlywhatthehealthproblemis.
r9 ba r 9
DIF: CognitiveLevel:Apply(application) ba REF: 7
TOP: NursingProcess: Diagnosis r9 MSC: r NCLEX:PhysiologicalIntegrity
9
, 6. Apatientwithabacterialinfectionhas a nursingdiagnosisof deficient fluidvolume relatedto
ba ba r9 ba ba ba ba ba ba
r9 excessivediaphoresis.Which outcome would the nurse recognize asappropriate forthispatient? r9 ba
a. Patienthasa balancedintakeand output. ba ba r9
b. Patient’sbeddingischanged when itbecomes damp. ba ba ba r9
c. Patientunderstandstheneedforincreased fluid intake. ba ba
d. Patient’sskin remainscooland drythroughout hospitalization.
ba ba ba r9
ANS: A r 9
Thisstatementgivesmeasurabledatashowingresolutionoftheproblemofdeficientfluidvolume
ba
thatwasidentifiedinthenursing diagnosisstatement.Theotherstatementswouldnot indicate that
r9 ba ba ba ba r9
theproblemofdeficientfluidvolumewasresolved.
r9
DIF: CognitiveLevel:Apply(application) ba REF: 7
TOP: NursingProcess:Planning ba r9 MSC: r NCLEX:PhysiologicalIntegrity
9
7. Anurseasks thepatientifpainwasrelievedafterreceivingmedication.Whatisthe purposeofthe
ba ba ba ba ba r9
r9 evaluationphaseofthenursing process? ba
a. Todetermineifinterventionshavebeeneffectiveinmeetingpatientoutcomes ba r9
b. Todocumentthe nursingcareplan in theprogress notesofthemedicalrecord ba ba ba r9
c. Todecidewhetherthepatient’shealthproblemshavebeencompletelyresolved r9
d. Toestablishifthepatientagreesthatthenursingcareprovidedwas satisfactory ba ba r 9 r 9
ANS: A r 9
Evaluation consists of determining whether the desired patient outcomes have been met and
r9 r9 r9 r9 r9 r9 r9 r9 r9 r9 r9 r9
whether the nursing interventions were appropriate. The other responses do not describe the
r9 r9 r9 r9 r9 r9 r9 r9 r9 r9 r9 r9 r9
evaluationphase.
r9
DIF: CognitiveLevel: Understand(comprehension) REF: 5 r9
TOP: Nursing Process:Evaluation MSC: NCLEX:SafeandEffectiveCareEnvironment
ba r 9 ba
8. Thenurseinterviews apatientwhilecompletingthehealthhistoryandphysicalexamination.What ba ba ba ba r9
isthepurposeoftheassessmentphaseofthenursingprocess?
r9
a. Toteachinterventionsthatrelievehealthproblems ba
b. Tousepatientdatatoevaluatepatientcareoutcomes ba
c. Toobtaindatawithwhichtodiagnosepatientproblems ba
d. Tohelpthepatientidentifyrealisticoutcomesforhealthproblems
ANS: C r 9
Duringtheassessmentphase,thenursegathersinformationabout thepatienttodiagnosepatient
ba ba r9
problems.Theotherresponsesareexamplesoftheplanning,intervention,and evaluation phasesof
r9 r9 r9 r9 ba ba
thenursingprocess.
r9
DIF: CognitiveLevel: Understand(comprehension) REF: 5 r9
TOP: NursingProcess:Assessment MSC: NCLEX:SafeandEffectiveCareEnvironment
ba r 9 ba ba
9. Which nursingdiagnosisstatementiswrittencorrectly?
ba r9 ba
a. Altered tissue perfusionrelatedtoheart failure
ba ba r9 ba
b. Risk forimpaired tissueintegrityrelated tosacralredness
b r9 ba r9
c. Ineffectivecopingrelatedtoresponsetobiopsytestresults
d. Altered urinaryeliminationrelatedtourinarytractinfection
ba r9
LewisTest-Bank.
r9
,Chapter01:ProfessionalNursingPracticeLewis:
r9 r9 r9 r9 r9
Medical-SurgicalNursing,10thEdition a
b a
b
MULTIPLECHOICE
1. Thenursecompletesanadmissiondatabaseandexplainsthattheplanofcareanddischargegoals r 9
r willbedevelopedwiththepatient’sinput.Thepatient states,“Howisthisdifferentfromwhatthe
9 ba ba r9
doctordoes?”Whichresponsewouldbemostappropriateforthenursetomake?
r9 r9 r9 r9
a. “Theroleofthenurseistoadministermedicationsand othertreatmentsprescribedby ba ba r9
yourdoctor.”r9
b. “Thenurse’sjobistohelpthedoctorbycollectinginformationand r9 ba
communicatinganyproblemsthatoccur.”
r9
c. “Nursesperformmanyofthesameproceduresasthedoctor, but nurses arewiththe ba r9 ba ba ba r9
patientsforalongertimethanthedoctor.”
r9
d. “Inadditiontocaringforyouwhile youaresick,thenurseswillassist youto
ba r9 ba ba
developanindividualizedplantomaintainyourhealth.”
r9
ANS: D r 9
ThisresponseisconsistentwiththeAmericanNursesAssociation(ANA)definitionofnursing, r9 r9 r9 r9
which describestheroleofnursesinpromotinghealth.Theotherresponsesdescribe someofthe
r9 ba r9 ba
dependent andcollaborative functionsofthenursing role butdonotaccuratelydescribethenurse’s
r9 ba r9
r roleinthehealthcaresystem.
9
DIF: CognitiveLevel:Understand(comprehension) REF: 3 ba ba
TOP: NursingProcess: Implementation MSC: NCLEX:SafeandEffectiveCareEnvironment r9 r 9 ba
2. Thenursedescribestoastudentnursehowtouseevidence-basedpracticeguidelineswhen
r 9 caringforpatients.Whichstatement,ifmadebythenurse,wouldbethemost accurate? r9 r9 r9 r9 r9 r9 r9
a. “Inferencesfrom clinicalresearchstudiesareusedasa guide.” ba r9 ba r9 ba ba
b. “Patientcareisbasedonclinicaljudgment,experience, and traditions.” r9 ba
c. “Data are evaluatedtoshowthatthepatientoutcomesareconsistentlymet.”
ba r 9 ba
d. “Recommendationsarebasedonresearch,clinicalexpertise,andpatient ba ba ba ba ba
preferences.”
r9
ANS: D r 9
Evidence-basedpractice(EBP)istheuseofthebestresearch-basedevidencecombinedwith r9
clinicianexpertise.Clinicaljudgmentbased onthenurse’sclinicalexperienceispartofEBP,but
r 9 ba ba ba ba r9
clinical decisionmakingshouldalsoincorporatecurrentresearchandresearch-based guidelines.
r9 ba ba ba r 9
r Evaluationof patientoutcomesisimportant,but interventionsshouldbebasedonresearchfrom
9 ba ba ba ba r9
randomized controlstudieswithalargenumberofsubjects.
r9 ba
DIF: CognitiveLevel:Remember(knowledge) ba REF: 15
TOP: NursingProcess:Planning MSC: ba r9 r 9 NCLEX:SafeandEffectiveCareEnvironment ba
3. Thenurseteachesastudentnurseabouthowtoapplythenursingprocesswhenproviding ba ba
patientcare. Whichstatement, ifmadebythestudentnurse,indicatesthatteachingwas
r9 r9 r9
successful?
r9
a. “Thenursingprocessisascientific-basedmethodofdiagnosingthepatient’s ba ba ba
healthcareproblems.”
r9
b. “Thenursing processisaproblem-solving toolused toidentifyandtreat patients’
ba ba r9 ba r9 ba ba
, healthcareneeds.” ba
c. “Thenursingprocessisusedprimarilytoexplainnursinginterventionstoother
ba ba ba ba ba
healthcareprofessionals.”
r 9
d. “Thenursingprocessisbasedonnursingtheorythatincorporatesthe
ba ba ba ba ba
biopsychosocialnatureofhumans.”
r9
ANS: B r 9
Thenursingprocessisaproblem-solvingapproachtotheidentificationandtreatmentofpatients’ ba r 9
r problems.Diagnosisisonlyonephaseofthenursingprocess.Theprimaryuseofthe
9 r9 ba
nursingprocess isinpatientcare,
r9 r9
nottoestablishnursingtheoryorexplainnursing interventionstootherhealthcare professionals.
r9 ba r 9
DIF: CognitiveLevel:Understand(comprehension) REF: 5 ba
TOP: NursingProcess: Implementation MSC: NCLEX:SafeandEffectiveCareEnvironment r9 r 9 ba
4. Apatienthasbeenadmittedtothehospitalforsurgeryandtellsthenurse,“Idonotfeel ba ba r 9 r 9
r 9 comfortableleavingmychildrenwithmyparents.”Whichactionshouldthenursetakenext?
ba ba ba ba ba ba
a. Reassurethepatient that thesefeelingsarecommonforparents. ba r9
b. Havethepatientcallthe childrentoensurethat theyaredoingwell. r9 ba
c. Gathermoredataabout thepatient’sfeelingsaboutthechild-carearrangements. ba ba
d. Callthepatient’sparentstodeterminewhetheradequatechildcareisbeing
ba ba
provided.
r9
ANS: C r 9
Becauseacompleteassessmentisnecessaryinordertoidentifyaproblemandchoosean ba ba r 9
r appropriateintervention,thenurse’sfirstactionshould be toobtainmoreinformation.Theother
9 r9 r9 r9 r9 ba r9
actionsmaybeappropriate,butmoreassessmentisneeded beforethebestinterventioncanbe
r9 ba ba r9
chosen.
r9
DIF: CognitiveLevel:Apply(application) REF: 6
OBJ: SpecialQuestions:Prioritization r9 r9 TOP: NursingProcess:Assessment
r9 ba
MSC: NCLEX:PsychosocialIntegrity
r9 r 9 r9 r9
5. Apatient whoisparalyzed ontheleftsideofthebodyafterastrokedevelops a pressure ulceronthe
ba ba ba r9 ba ba ba r9
r9 lefthip.Which nursingdiagnosisismostappropriate?
r9 ba r9 r9
a. Impairedphysicalmobilityrelatedtoleft-sidedparalysis
b. Risk forimpaired tissueintegrityrelatedtoleft-sidedweakness
ba r 9
c. Impairedskinintegrityrelated toaltered circulationandpressure ba ba r9
d. Ineffectivetissueperfusionrelatedtoinabilitytomoveindependently
ANS: C r 9
Thepatient’smajorproblemistheimpairedskinintegrityasdemonstrated bythepresence ofa r9 ba
r pressureulcer.Thenurseisabletotreatthecauseofalteredcirculationandpressurebyfrequently
9 ba r 9
r repositioningthepatient.Althoughleft-sidedweaknessisaproblem forthepatient,
9 r 9 ba ba ba ba
thenursecannot treattheweakness.The“riskfor”diagnosisisnot appropriateforthispatient,
r9 r9 ba ba
whoalreadyhas impairedtissueintegrity.The patient doeshave ineffectivetissue perfusion,
r9 r9 r9 ba
but theimpaired skin integritydiagnosisindicatesmoreclearlywhatthehealthproblemis.
r9 ba r 9
DIF: CognitiveLevel:Apply(application) ba REF: 7
TOP: NursingProcess: Diagnosis r9 MSC: r NCLEX:PhysiologicalIntegrity
9
, 6. Apatientwithabacterialinfectionhas a nursingdiagnosisof deficient fluidvolume relatedto
ba ba r9 ba ba ba ba ba ba
r9 excessivediaphoresis.Which outcome would the nurse recognize asappropriate forthispatient? r9 ba
a. Patienthasa balancedintakeand output. ba ba r9
b. Patient’sbeddingischanged when itbecomes damp. ba ba ba r9
c. Patientunderstandstheneedforincreased fluid intake. ba ba
d. Patient’sskin remainscooland drythroughout hospitalization.
ba ba ba r9
ANS: A r 9
Thisstatementgivesmeasurabledatashowingresolutionoftheproblemofdeficientfluidvolume
ba
thatwasidentifiedinthenursing diagnosisstatement.Theotherstatementswouldnot indicate that
r9 ba ba ba ba r9
theproblemofdeficientfluidvolumewasresolved.
r9
DIF: CognitiveLevel:Apply(application) ba REF: 7
TOP: NursingProcess:Planning ba r9 MSC: r NCLEX:PhysiologicalIntegrity
9
7. Anurseasks thepatientifpainwasrelievedafterreceivingmedication.Whatisthe purposeofthe
ba ba ba ba ba r9
r9 evaluationphaseofthenursing process? ba
a. Todetermineifinterventionshavebeeneffectiveinmeetingpatientoutcomes ba r9
b. Todocumentthe nursingcareplan in theprogress notesofthemedicalrecord ba ba ba r9
c. Todecidewhetherthepatient’shealthproblemshavebeencompletelyresolved r9
d. Toestablishifthepatientagreesthatthenursingcareprovidedwas satisfactory ba ba r 9 r 9
ANS: A r 9
Evaluation consists of determining whether the desired patient outcomes have been met and
r9 r9 r9 r9 r9 r9 r9 r9 r9 r9 r9 r9
whether the nursing interventions were appropriate. The other responses do not describe the
r9 r9 r9 r9 r9 r9 r9 r9 r9 r9 r9 r9 r9
evaluationphase.
r9
DIF: CognitiveLevel: Understand(comprehension) REF: 5 r9
TOP: Nursing Process:Evaluation MSC: NCLEX:SafeandEffectiveCareEnvironment
ba r 9 ba
8. Thenurseinterviews apatientwhilecompletingthehealthhistoryandphysicalexamination.What ba ba ba ba r9
isthepurposeoftheassessmentphaseofthenursingprocess?
r9
a. Toteachinterventionsthatrelievehealthproblems ba
b. Tousepatientdatatoevaluatepatientcareoutcomes ba
c. Toobtaindatawithwhichtodiagnosepatientproblems ba
d. Tohelpthepatientidentifyrealisticoutcomesforhealthproblems
ANS: C r 9
Duringtheassessmentphase,thenursegathersinformationabout thepatienttodiagnosepatient
ba ba r9
problems.Theotherresponsesareexamplesoftheplanning,intervention,and evaluation phasesof
r9 r9 r9 r9 ba ba
thenursingprocess.
r9
DIF: CognitiveLevel: Understand(comprehension) REF: 5 r9
TOP: NursingProcess:Assessment MSC: NCLEX:SafeandEffectiveCareEnvironment
ba r 9 ba ba
9. Which nursingdiagnosisstatementiswrittencorrectly?
ba r9 ba
a. Altered tissue perfusionrelatedtoheart failure
ba ba r9 ba
b. Risk forimpaired tissueintegrityrelated tosacralredness
b r9 ba r9
c. Ineffectivecopingrelatedtoresponsetobiopsytestresults
d. Altered urinaryeliminationrelatedtourinarytractinfection
ba r9
