Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
NURSINGTB.COM
, Medical-
Chapter 01: Introduction
]+ to Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
Surgical Nursing Practice in Canada Lewis: Medical-
]+ ]+ ]+ ]+ ]+ ]+
Surgical Nursing in Canada, 5th Canadian Edition
]+ ]+ ]+ ]+ ]+ ]+
MULTIPLE CHOICE ]+
1. When caring for clients using evidence-
]+ ]+ ]+ ]+ ]+
informed practice, which of the following does the nurse use?
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
a. Clinical judgement based on experience ]+ ]+ ]+ ]+
b. Evidence from a clinical research study ]+ ]+ ]+ ]+ ]+
c. The best available evidence to guide clinical expertise
]+ ]+ ]+ ]+ ]+ ]+ ]+
d. Evaluation of data showing that the client outcomes are met ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
ANS: C ] +
Evidence-
informed nursing practice is a continuous interactive process involving the explicit, conscient
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
ious, and judicious consideration of the best available evidence to provide care. Four primary
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
elements are: (a) clinical state, setting, and circumstances; (b) client preferences and actions;
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
(c) best research evidence; and (d) health care resources. Clinical judgement based on the nur
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
se‘s clinical experience is part of EIP, but clinical decision making also should incorporate c
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
urrent research and research-
]+ ]+ ]+
based guidelines. Evidence from one clinical research study does not provide an adequate su
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
bstantiation for interventions. Evaluation of client outcomes is important, but interventions s
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
hould be based on research from randomized control studies with a large number of subjects
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
.
DIF: Cognitive Level: Comprehension ]+ ]+ TOP: ] + Nursing Process: Planning ]+ ]+
2. Which of the following best e xpl a ins the nu r s e s ‘ primary use of the nursing process when
]+
N R I G B . C M
]+ ]+ ]+ ]+ +
] +
] ]+ +
] +
] +
] +
] ]+ ]+ ] + ]+ ]+ ]+ ]+ ]+ ]+ ]+
providing care to clients? USNT ]+
O ]+ ]+
]+ ]+ ]+
a. To explain nursing interventions to other health care professionals
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
b. As a problem-solving tool to identify and treat clients‘ health care needs
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
c. As a scientific-based process of diagnosing the client‘s health care problems
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
d. To establish nursing theory that incorporates the biopsychosocial nature of humans
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
ANS: B ] +
The nursing process is an assertive problem-
]+ ]+ ]+ ]+ ]+ ]+
solving approach to the identification and treatment of clients‘ problems. Diagnosis is only
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
one phase of the nursing process. The primary use of the nursing process is in client care, not
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]
+to establish nursing theory or explain nursing interventions to other health care professionals
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
.
DIF: Cognitive Level: Comprehension ]+ ]+ TOP: ] + Nursing Process: Implementation ]+ ]+
3. The nurse is caring for a critically ill client in the intensive care unit and plans an every 2-
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
hour turning schedule to prevent skin breakdown. Which type of nursing function is demons
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
trated with this turning schedule?
]+ ]+ ]+ ]+
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: D ] +
NURSINGTB.COM
, Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
When implementing collaborative nursing actions, the nurse is responsible primarily for mon
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
itoring for complications of acute illness or providing care to prevent or treat complications.
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]
+Independent nursing actions are focused on health promotion, illness prevention, and client
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
advocacy. A dependent action would require a physician order to implement. Cooperative nu
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
rsing functions are not described as one of the formal nursing functions.
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
DIF: Cognitive Level: Application ]+ ]+ TOP: ] + Nursing Process: Implementation ]+ ]+
4. The nurse is caring for a client who has been admitted to the hospital for surgery and tells th
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
e nurse, ―I do not feel right about leaving my children with my neighbour.‖ Which action
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]
should the nurse take next?
+ ]+ ]+ ]+ ]+
a. Reassure the client that these feelings are common for parents. ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
b. Have the client call the children to ensure that they are doing well.
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
c. Call the neighbour to determine whether adequate childcare is being provided.
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
d. Gather more data about the client‘s feelings about the childcare arrangements.
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
ANS: D ] +
Since a complete assessment is necessary in order to identify a problem and choose an appr
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
opriate 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 intervention can be
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
chosen.
]+
DIF: Cognitive Level: Application ]+ ]+ TOP: ] + Nursing Process: Assessment ]+ ]+
5. The nurse is caring for a client who has left-
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
sided paralysis as the result of a stroke and assesses a pressure injury on the clie nt‘s l
N R isIthe most
G Bappropriate
.C M nursing diagnosis f Uo r t Sh is cNli
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
eft h ip . W hich of the following
]+ ]+ +
] ]+ ]+ +
] ]+ ]+ ]+
] + ] +
]+ ]+
] +
]+
] +
]+
+
] +
] ] +
]+ ]+ ]+ ]+ ]+ +
] +
] ]+ +
] +
]
enTt?+
] +
] O
a. Impaired physical mobility related to decrease in muscle control (left-sided
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
paralysis)
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge about
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
protecting tissue integrity
]+ ]+ ]+
c. Impaired skin integrity related to pressure over bony prominence (impaired
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]
circulation) +
d. Ineffective tissue perfusion related to sedentary lifestyle ]+ ]+ ]+ ]+ ]+ ]+
ANS: C ] +
The client‘s major problem is the impaired skin integrity as demonstrated by the presence of a
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]
+pressure injury. The nurse is able to treat the cause of altered circulation and pressure by fr
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
equently repositioning the client. Although left-
]+ ]+ ]+ ]+ ]+
sided weakness is a problem for the client, the nurse cannot treat the weakness. The ―risk fo
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
r‖ diagnosis is not appropriate for this client, who already has impaired tissue integrity. The c
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
lient does have ineffective tissue perfusion, but the impaired skin integrity diagnosis indicat
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
es more clearly what the health problem is.
]+ ]+ ]+ ]+ ]+ ]+ ]+
DIF: Cognitive Level: Application ]+ ]+ TOP: ] + Nursing Process: Diagnosis ]+ ]+
6. The nurse caring for a client with an infection has a nursing diagnosis of deficient flui
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
d volume related to excessive diaphoresis. Which of the following is an appropriate cli
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
ent outcome? ]+
a. Client has a balanced intake and output. ]+ ]+ ]+ ]+ ]+ ]+
b. Client‘s bedding is changed when it becomes damp. ]+ ]+ ]+ ]+ ]+ ]+ ]+
NURSINGTB.COM
, Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
c. Client understands the need for increased fluid intake.
]+ ]+ ]+ ]+ ]+ ]+ ]+
d. Client‘s skin remains cool and dry throughout hospitalization.
]+ ]+ ]+ ]+ ]+ ]+ ]+
ANS: A ] +
This statement gives measurable data showing resolution of the problem of deficient fluid v
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
olume that was identified in the nursing diagnosis statement. The other statements would not i
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
ndicate that the problem of deficient fluid volume was resolved.
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
DIF: Cognitive Level: Application ]+ ]+ TOP: ] + Nursing Process: Planning ]+ ]+
7. Which of the following represents a nursing activity that is carried out during the evaluatio
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
n phase of the nursing process?
]+ ]+ ]+ ]+ ]+
a. Determining if interventions have been effective in meeting client outcomes ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
b. Documenting the nursing care plan in the progress notes in the medical record ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
c. Deciding whether the client‘s health problems have been completely resolved
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
d. Asking the client to evaluate whether the nursing care provided was satisfactory
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
ANS: A ] +
Evaluation consists of determining whether the desired client outcomes have been met and
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
whether the nursing interventions were appropriate. The other responses do not describe the e
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
valuation phase. ]+
DIF: Cognitive Level: Comprehension ]+ ]+ TOP: ] + Nursing Process: Evaluation ]+ ]+
8. Which of the following would the nurse perform during the assessment phase of the nursin
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
g process?
]+
a. Obtains data with which to diagnose client problems
]+ ]+ ]+ ]+ ]+ ]+ ]+
b. Uses client data to develoNp p R
ri o riIt y nGursB
U S N T in.
]+ gC
diagMnoses
c. Teaches interventions to relieve client health problems
]+
]+ ]+ ]+
]+
]+
]+
]+ ]+
]+
]+ ] +
]+
]+
]+
]+
d. Assists the client to identify realistic outcomes to health problems
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
ANS: A ] +
During the assessment phase, the nurse gathers information about the client. The other respo
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
nses are examples of the intervention, diagnosis, and planning phases of the nursing process.
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
DIF: Cognitive Level: Knowledge ]+ ]+ TOP: ] + Nursing Process: Assessment ]+ ]+
9. Which of the following is an example of a correctly written nursing diagnosis statement?
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
a. Altered tissue perfusion related to heart failure]+ ]+ ]+ ]+ ]+ ]+
b. Risk for impaired tissue integrity related to sacral redness
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
c. Ineffective coping related to insufficient sense of control. ]+ ]+ ]+ ]+ ]+ ]+ ]+
d. Altered urinary elimination related to urinary tract infection
]+ ]+ ]+ ]+ ]+ ]+ ]+
ANS: C ] +
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describe
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
s a client‘s response to a health problem that can be treated by nursing. The use of a medic
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
al diagnosis (as in the responses beginning ―Altered tissue perfusion‖ and ―Altered urinary
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]
elimination‖) is not appropriate. The response beginning ―Risk for impaired tissue integrit
+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
y‖ uses the defining characteristics as the etiology.
]+ ]+ ]+ ]+ ]+ ]+ ]+
DIF: Cognitive Level: Comprehension ]+ ]+ TOP: ] + Nursing Process: Diagnosis ]+ ]+
NURSINGTB.COM
Surgical Nursing in Canada 5th Edition Lewi Test Bank
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
NURSINGTB.COM
, Medical-
Chapter 01: Introduction
]+ to Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
Surgical Nursing Practice in Canada Lewis: Medical-
]+ ]+ ]+ ]+ ]+ ]+
Surgical Nursing in Canada, 5th Canadian Edition
]+ ]+ ]+ ]+ ]+ ]+
MULTIPLE CHOICE ]+
1. When caring for clients using evidence-
]+ ]+ ]+ ]+ ]+
informed practice, which of the following does the nurse use?
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
a. Clinical judgement based on experience ]+ ]+ ]+ ]+
b. Evidence from a clinical research study ]+ ]+ ]+ ]+ ]+
c. The best available evidence to guide clinical expertise
]+ ]+ ]+ ]+ ]+ ]+ ]+
d. Evaluation of data showing that the client outcomes are met ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
ANS: C ] +
Evidence-
informed nursing practice is a continuous interactive process involving the explicit, conscient
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
ious, and judicious consideration of the best available evidence to provide care. Four primary
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
elements are: (a) clinical state, setting, and circumstances; (b) client preferences and actions;
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
(c) best research evidence; and (d) health care resources. Clinical judgement based on the nur
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
se‘s clinical experience is part of EIP, but clinical decision making also should incorporate c
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
urrent research and research-
]+ ]+ ]+
based guidelines. Evidence from one clinical research study does not provide an adequate su
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
bstantiation for interventions. Evaluation of client outcomes is important, but interventions s
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
hould be based on research from randomized control studies with a large number of subjects
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
.
DIF: Cognitive Level: Comprehension ]+ ]+ TOP: ] + Nursing Process: Planning ]+ ]+
2. Which of the following best e xpl a ins the nu r s e s ‘ primary use of the nursing process when
]+
N R I G B . C M
]+ ]+ ]+ ]+ +
] +
] ]+ +
] +
] +
] +
] ]+ ]+ ] + ]+ ]+ ]+ ]+ ]+ ]+ ]+
providing care to clients? USNT ]+
O ]+ ]+
]+ ]+ ]+
a. To explain nursing interventions to other health care professionals
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
b. As a problem-solving tool to identify and treat clients‘ health care needs
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
c. As a scientific-based process of diagnosing the client‘s health care problems
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
d. To establish nursing theory that incorporates the biopsychosocial nature of humans
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
ANS: B ] +
The nursing process is an assertive problem-
]+ ]+ ]+ ]+ ]+ ]+
solving approach to the identification and treatment of clients‘ problems. Diagnosis is only
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
one phase of the nursing process. The primary use of the nursing process is in client care, not
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]
+to establish nursing theory or explain nursing interventions to other health care professionals
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
.
DIF: Cognitive Level: Comprehension ]+ ]+ TOP: ] + Nursing Process: Implementation ]+ ]+
3. The nurse is caring for a critically ill client in the intensive care unit and plans an every 2-
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
hour turning schedule to prevent skin breakdown. Which type of nursing function is demons
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
trated with this turning schedule?
]+ ]+ ]+ ]+
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: D ] +
NURSINGTB.COM
, Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
When implementing collaborative nursing actions, the nurse is responsible primarily for mon
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
itoring for complications of acute illness or providing care to prevent or treat complications.
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]
+Independent nursing actions are focused on health promotion, illness prevention, and client
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
advocacy. A dependent action would require a physician order to implement. Cooperative nu
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
rsing functions are not described as one of the formal nursing functions.
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
DIF: Cognitive Level: Application ]+ ]+ TOP: ] + Nursing Process: Implementation ]+ ]+
4. The nurse is caring for a client who has been admitted to the hospital for surgery and tells th
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
e nurse, ―I do not feel right about leaving my children with my neighbour.‖ Which action
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]
should the nurse take next?
+ ]+ ]+ ]+ ]+
a. Reassure the client that these feelings are common for parents. ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
b. Have the client call the children to ensure that they are doing well.
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
c. Call the neighbour to determine whether adequate childcare is being provided.
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
d. Gather more data about the client‘s feelings about the childcare arrangements.
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
ANS: D ] +
Since a complete assessment is necessary in order to identify a problem and choose an appr
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
opriate 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 intervention can be
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
chosen.
]+
DIF: Cognitive Level: Application ]+ ]+ TOP: ] + Nursing Process: Assessment ]+ ]+
5. The nurse is caring for a client who has left-
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
sided paralysis as the result of a stroke and assesses a pressure injury on the clie nt‘s l
N R isIthe most
G Bappropriate
.C M nursing diagnosis f Uo r t Sh is cNli
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
eft h ip . W hich of the following
]+ ]+ +
] ]+ ]+ +
] ]+ ]+ ]+
] + ] +
]+ ]+
] +
]+
] +
]+
+
] +
] ] +
]+ ]+ ]+ ]+ ]+ +
] +
] ]+ +
] +
]
enTt?+
] +
] O
a. Impaired physical mobility related to decrease in muscle control (left-sided
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
paralysis)
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge about
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
protecting tissue integrity
]+ ]+ ]+
c. Impaired skin integrity related to pressure over bony prominence (impaired
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]
circulation) +
d. Ineffective tissue perfusion related to sedentary lifestyle ]+ ]+ ]+ ]+ ]+ ]+
ANS: C ] +
The client‘s major problem is the impaired skin integrity as demonstrated by the presence of a
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]
+pressure injury. The nurse is able to treat the cause of altered circulation and pressure by fr
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
equently repositioning the client. Although left-
]+ ]+ ]+ ]+ ]+
sided weakness is a problem for the client, the nurse cannot treat the weakness. The ―risk fo
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
r‖ diagnosis is not appropriate for this client, who already has impaired tissue integrity. The c
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
lient does have ineffective tissue perfusion, but the impaired skin integrity diagnosis indicat
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
es more clearly what the health problem is.
]+ ]+ ]+ ]+ ]+ ]+ ]+
DIF: Cognitive Level: Application ]+ ]+ TOP: ] + Nursing Process: Diagnosis ]+ ]+
6. The nurse caring for a client with an infection has a nursing diagnosis of deficient flui
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
d volume related to excessive diaphoresis. Which of the following is an appropriate cli
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
ent outcome? ]+
a. Client has a balanced intake and output. ]+ ]+ ]+ ]+ ]+ ]+
b. Client‘s bedding is changed when it becomes damp. ]+ ]+ ]+ ]+ ]+ ]+ ]+
NURSINGTB.COM
, Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
c. Client understands the need for increased fluid intake.
]+ ]+ ]+ ]+ ]+ ]+ ]+
d. Client‘s skin remains cool and dry throughout hospitalization.
]+ ]+ ]+ ]+ ]+ ]+ ]+
ANS: A ] +
This statement gives measurable data showing resolution of the problem of deficient fluid v
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
olume that was identified in the nursing diagnosis statement. The other statements would not i
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
ndicate that the problem of deficient fluid volume was resolved.
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
DIF: Cognitive Level: Application ]+ ]+ TOP: ] + Nursing Process: Planning ]+ ]+
7. Which of the following represents a nursing activity that is carried out during the evaluatio
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
n phase of the nursing process?
]+ ]+ ]+ ]+ ]+
a. Determining if interventions have been effective in meeting client outcomes ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
b. Documenting the nursing care plan in the progress notes in the medical record ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
c. Deciding whether the client‘s health problems have been completely resolved
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
d. Asking the client to evaluate whether the nursing care provided was satisfactory
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
ANS: A ] +
Evaluation consists of determining whether the desired client outcomes have been met and
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
whether the nursing interventions were appropriate. The other responses do not describe the e
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
valuation phase. ]+
DIF: Cognitive Level: Comprehension ]+ ]+ TOP: ] + Nursing Process: Evaluation ]+ ]+
8. Which of the following would the nurse perform during the assessment phase of the nursin
]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+ ]+
g process?
]+
a. Obtains data with which to diagnose client problems
]+ ]+ ]+ ]+ ]+ ]+ ]+
b. Uses client data to develoNp p R
ri o riIt y nGursB
U S N T in.
]+ gC
diagMnoses
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: A ] +
During the assessment phase, the nurse gathers information about the client. The other respo
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nses are examples of the intervention, diagnosis, and planning phases of the nursing process.
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DIF: Cognitive Level: Knowledge ]+ ]+ TOP: ] + Nursing Process: Assessment ]+ ]+
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]+ ]+ ]+ ]+ ]+ ]+
b. Risk for impaired tissue integrity related to sacral redness
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c. Ineffective coping related to insufficient sense of control. ]+ ]+ ]+ ]+ ]+ ]+ ]+
d. Altered urinary elimination related to urinary tract infection
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ANS: C ] +
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describe
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s a client‘s response to a health problem that can be treated by nursing. The use of a medic
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al diagnosis (as in the responses beginning ―Altered tissue perfusion‖ and ―Altered urinary
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elimination‖) is not appropriate. The response beginning ―Risk for impaired tissue integrit
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y‖ uses the defining characteristics as the etiology.
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DIF: Cognitive Level: Comprehension ]+ ]+ TOP: ] + Nursing Process: Diagnosis ]+ ]+
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