Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
z% z% z% z% z% z% z% z%
NURSINGTB.COM
, Medical-
Chapter 01: Introduction
z% to Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
z% z% z% z%
z% z% z% z% z% z% z%
Surgical Nursing Practice in Canada Lewis: Medical-
z% z% z% z% z% z%
Surgical Nursing in Canada, 5th Canadian Edition
z% z% z% z% z% z%
MULTIPLE CHOICE z%
1. When caring for clients using evidence-
z% z% z% z% z%
informed practice, which of the following does the nurse use?
z% z% z% z% z% z% z% z% z%
a. Clinical judgement based on experience z% z% z% z%
b. Evidence from a clinical research study z% z% z% z% z%
c. The best available evidence to guide clinical expertise
z% z% z% z% z% z% z%
d. Evaluation of data showing that the client outcomes are met
z% z% z% z% z% z% z% z% z%
ANS: z % C
Evidence-
informed nursing practice is a continuous interactive process involving the explicit, consc
z% z% z% z% z% z% z% z% z% z% z%
ientious, and judicious consideration of the best available evidence to provide care. Four p
z% z% z% z% z% z% z% z% z% z% z% z% z%
rimary elements are: (a) clinical state, setting, and circumstances; (b) client preferences a
z% z% z% z% z% z% z% z% z% z% z% z%
nd actions; (c) best research evidence; and (d) health care resources. Clinical judgement b
z% z% z% z% z% z% z% z% z% z% z% z% z%
ased on the nurse‘s clinical experience is part of EIP, but clinical decision making also
z% z% z% z% z% z% z% z% z% z% z% z% z% z% z%
should incorporate current research and research-
z% z% z% z% z%
based guidelines. Evidence from one clinical research study does not provide an adequat
z% z% z% z% z% z% z% z% z% z% z% z%
e substantiation for interventions. Evaluation of client outcomes is important, but interve
z% z% z% z% z% z% z% z% z% z% z%
ntions should be based on research from randomized control studies with a large numbe
z% z% z% z% z% z% z% z% z% z% z% z% z%
r of subjects.
z% z%
DIF: Cognitive Level: Comprehension z% z% TOP: z % Nursing Process: Planning z% z%
2. Which of the following best e xp l a i n s th e n u r s e s ‘ primary use of the nursing process
z%
N R I G B . C M
z% z% z% z% z% z% z% z% z% z% z% z% z% z % z% z% z% z% z%
when providing care to clients?
z% z%
USNT O z% z% z%
z% z% z%
a. To explain nursing interventions to other health care professionals
z% z% z% z% z% z% z% z%
b. As a problem-solving tool to identify and treat clients‘ health care needs
z% z% z% z% z% z% z% z% z% z% z%
c. As a scientific-based process of diagnosing the client‘s health care problems
z% z% z% z% z% z% z% z% z% z%
d. To establish nursing theory that incorporates the biopsychosocial nature of humans
z% z% z% z% z% z% z% z% z% z%
ANS: z % B
The nursing process is an assertive problem-
z% z% z% z% z% z%
solving approach to the identification and treatment of clients‘ problems. Diagnosis is on
z% z% z% z% z% z% z% z% z% z% z% z%
ly one phase of the nursing process. The primary use of the nursing process is in client
z% z% z% z% z% z% z% z% z% z% z% z% z% z% z% z% z%
care, not to establish nursing theory or explain nursing interventions to other health care
z% z% z% z% z% z% z% z% z% z% z% z% z% z%
professionals.
DIF: Cognitive Level: Comprehension z% z% TOP: z % Nursing Process: Implementation z% z%
3. The nurse is caring for a critically ill client in the intensive care unit and plans an every
z% z% z% z% z% z% z% z% z% z% z% z% z% z% z% z% z% z%
2-
hour turning schedule to prevent skin breakdown. Which type of nursing function is de
z% z% z% z% z% z% z% z% z% z% z% z% z%
monstrated with this turning schedule? z% z% z% z%
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: z % D
NURSINGTB.COM
, Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
z% z% z% z% z% z% z% z%
When implementing collaborative nursing actions, the nurse is responsible primarily for
z% z% z% z% z% z% z% z% z% z% z%
monitoring for complications of acute illness or providing care to prevent or treat compl
z% z% z% z% z% z% z% z% z% z% z% z% z%
ications. Independent nursing actions are focused on health promotion, illness prevention,
z% z% z% z% z% z% z% z% z% z%
and client advocacy. A dependent action would require a physician order to implement.
z% z% z% z% z% z% z% z% z% z% z% z% z% z
%Cooperative nursing functions are not described as one of the formal nursing functions.
z% z% z% z% z% z% z% z% z% z% z% z%
DIF: Cognitive Level: Application z% z% TOP: z % Nursing Process: Implementation
z% z%
4. The nurse is caring for a client who has been admitted to the hospital for surgery and te
z% z% z% z% z% z% z% z% z% z% z% z% z% z% z% z% z%
lls the nurse, ―I do not feel right about leaving my children with my neighbour.‖ Whi
z% z% z% z% z% z% z% z% z% z% z% z% z% z% z%
ch action should the nurse take next?
z% z% z% z% z% z%
a. Reassure the client that these feelings are common for parents.
z% z% z% z% z% z% z% z% z%
b. Have the client call the children to ensure that they are doing well.
z% z% z% z% z% z% z% z% z% z% z% z%
c. Call the neighbour to determine whether adequate childcare is being provided.
z% z% z% z% z% z% z% z% z% z%
d. Gather more data about the client‘s feelings about the childcare arrangements.
z% z% z% z% z% z% z% z% z% z%
ANS: z % D
Since a complete assessment is necessary in order to identify a problem and choose an
z% z% z% z% z% z% z% z% z% z% z% z% z% z% z%
appropriate intervention, the nurse‘s first action should be to obtain more information. T
z% z% z% z% z% z% z% z% z% z% z% z%
he other actions may be appropriate, but more assessment is needed before the best interv
z% z% z% z% z% z% z% z% z% z% z% z% z% z%
ention can be chosen.
z% z% z%
DIF: Cognitive Level: Application z% z% TOP: z % Nursing Process: Assessment z% z%
5. The nurse is caring for a client who has left-
z% z% z% z% z% z% z% z% z%
sided paralysis as the result of a stroke and assesses a pressure injury on the clie
nt‘s left h i p . W hich ofNtheRfollowing
I G isBthe
.CmostM appropriate nursing diagnosis f Uo r
z% z% z% z% z% z% z% z% z% z% z% z% z% z% z% z%
z % z % z % z % %
z %
z z %
z% z% z% %
z z% z% z% z% z% z% z% z% z% z% z% z% z% z% z
%t Sh i s cNl i e nTt ?
z% z% z% z% z% z% O z%
a. Impaired physical mobility related to decrease in muscle control (left-sided
z% z% z% z% z% z% z% z% z%
paralysis)
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge ab
z% z% z% z% z% z% z% z% z% z%
out protecting tissue integrity
z% z% z%
c. Impaired skin integrity related to pressure over bony prominence (impai
z% z% z% z% z% z% z% z% z%
red circulation)z%
d. Ineffective tissue perfusion related to sedentary lifestyle
z% z% z% z% z% z%
ANS: z % C
The client‘s major problem is the impaired skin integrity as demonstrated by the presence
z% z% z% z% z% z% z% z% z% z% z% z% z% z
%of a pressure injury. The nurse is able to treat the cause of altered circulation and press
z% z% z% z% z% z% z% z% z% z% z% z% z% z% z% z%
ure by frequently repositioning the client. Although left-
z% z% z% z% z% z% z%
sided weakness is a problem for the client, the nurse cannot treat the weakness. The ―ri
z% z% z% z% z% z% z% z% z% z% z% z% z% z% z%
sk for‖ diagnosis is not appropriate for this client, who already has impaired tissue integri
z% z% z% z% z% z% z% z% z% z% z% z% z% z%
ty. The client does have ineffective tissue perfusion, but the impaired skin integrity diag
z% z% z% z% z% z% z% z% z% z% z% z% z%
nosis indicates more clearly what the health problem is.
z% z% z% z% z% z% z% z%
DIF: Cognitive Level: Application z% z% TOP: z % Nursing Process: Diagnosis z% z%
6. The nurse caring for a client with an infection has a nursing diagnosis of deficient
z% z% z% z% z% z% z% z% z% z% z% z% z% z%
fluid volume related to excessive diaphoresis. Which of the following is an appro
z% z% z% z% z% z% z% z% z% z% z% z% z%
priate client outcome?
z% z%
a. Client has a balanced intake and output.
z% z% z% z% z% z%
b. Client‘s bedding is changed when it becomes damp.
z% z% z% z% z% z% z%
NURSINGTB.COM
, Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
z% z% z% z% z% z% z% z%
c. Client understands the need for increased fluid intake.
z% z% z% z% z% z% z%
d. Client‘s skin remains cool and dry throughout hospitalization.
z% z% z% z% z% z% z%
ANS: z % A
This statement gives measurable data showing resolution of the problem of deficient flui
z% z% z% z% z% z% z% z% z% z% z% z%
d volume that was identified in the nursing diagnosis statement. The other statements wou
z% z% z% z% z% z% z% z% z% z% z% z% z%
ld not indicate that the problem of deficient fluid volume was resolved.
z% z% z% z% z% z% z% z% z% z% z%
DIF: Cognitive Level: Application z% z% TOP: z % Nursing Process: Planning z% z%
7. Which of the following represents a nursing activity that is carried out during the evalu
z% z% z% z% z% z% z% z% z% z% z% z% z% z%
ation phase of the nursing process?
z% z% z% z% z%
a. Determining if interventions have been effective in meeting client outcomes
z% z% z% z% z% z% z% z% z%
b. Documenting the nursing care plan in the progress notes in the medical record
z% z% z% z% z% z% z% z% z% z% z% z%
c. Deciding whether the client‘s health problems have been completely resolved
z% z% z% z% z% z% z% z% z%
d. Asking the client to evaluate whether the nursing care provided was satisfactory
z% z% z% z% z% z% z% z% z% z% z%
ANS: z % A
Evaluation consists of determining whether the desired client outcomes have been met a
z% z% z% z% z% z% z% z% z% z% z% z%
nd whether the nursing interventions were appropriate. The other responses do not describ
z% z% z% z% z% z% z% z% z% z% z% z%
e the evaluation phase.
z% z% z%
DIF: Cognitive Level: Comprehension z% z% TOP: z % Nursing Process: Evaluationz% z%
8. Which of the following would the nurse perform during the assessment phase of the nu
z% z% z% z% z% z% z% z% z% z% z% z% z% z%
rsing process? z%
a. Obtains data with which to diagnose client problems
z% z% z% z% z% z% z%
b. Uses client data to develoNp p R riIt y nGursB
in.
gCdiagMnoses
z%
UriSo N T z%
c. Teaches interventions to relieve client health problems
z%
z% z%
z%
z%
z%
z% z% z%
z%
z% z %
z%
z%
z%
d. Assists the client to identify realistic outcomes to health problems
z% z% z% z% z% z% z% z% z%
ANS: z % A
During the assessment phase, the nurse gathers information about the client. The other r
z% z% z% z% z% z% z% z% z% z% z% z% z%
esponses are examples of the intervention, diagnosis, and planning phases of the nursing
z% z% z% z% z% z% z% z% z% z% z% z% z%
process.
DIF: Cognitive Level: Knowledge z% z% TOP: z % Nursing Process: Assessmentz% z%
9. Which of the following is an example of a correctly written nursing diagnosis statement?
z% z% z% z% z% z% z% z% z% z% z% z% z%
a. Altered tissue perfusion related to heart failure
z% z% z% z% z% z%
b. Risk for impaired tissue integrity related to sacral redness
z% z% z% z% z% z% z% z%
c. Ineffective coping related to insufficient sense of control.
z% z% z% z% z% z% z%
d. Altered urinary elimination related to urinary tract infection
z% z% z% z% z% z% z%
ANS: z % C
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that descr
z% z% z% z% z% z% z% z% z% z% z% z%
ibes a client‘s response to a health problem that can be treated by nursing. The use of
z% z% z% z% z% z% z% z% z% z% z% z% z% z% z% z% z
%a medical diagnosis (as in the responses beginning ―Altered tissue perfusion‖ and ―Alt
z% z% z% z% z% z% z% z% z% z% z% z%
ered urinary elimination‖) is not appropriate. The response beginning ―Risk for impaire
z% z% z% z% z% z% z% z% z% z% z%
d tissue integrity‖ uses the defining characteristics as the etiology.
z% z% z% z% z% z% z% z% z%
DIF: Cognitive Level: Comprehension z% z% TOP: z % Nursing Process: Diagnosis z% z%
NURSINGTB.COM
Surgical Nursing in Canada 5th Edition Lewi Test Bank
z% z% z% z% z% z% z% z%
NURSINGTB.COM
, Medical-
Chapter 01: Introduction
z% to Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
z% z% z% z%
z% z% z% z% z% z% z%
Surgical Nursing Practice in Canada Lewis: Medical-
z% z% z% z% z% z%
Surgical Nursing in Canada, 5th Canadian Edition
z% z% z% z% z% z%
MULTIPLE CHOICE z%
1. When caring for clients using evidence-
z% z% z% z% z%
informed practice, which of the following does the nurse use?
z% z% z% z% z% z% z% z% z%
a. Clinical judgement based on experience z% z% z% z%
b. Evidence from a clinical research study z% z% z% z% z%
c. The best available evidence to guide clinical expertise
z% z% z% z% z% z% z%
d. Evaluation of data showing that the client outcomes are met
z% z% z% z% z% z% z% z% z%
ANS: z % C
Evidence-
informed nursing practice is a continuous interactive process involving the explicit, consc
z% z% z% z% z% z% z% z% z% z% z%
ientious, and judicious consideration of the best available evidence to provide care. Four p
z% z% z% z% z% z% z% z% z% z% z% z% z%
rimary elements are: (a) clinical state, setting, and circumstances; (b) client preferences a
z% z% z% z% z% z% z% z% z% z% z% z%
nd actions; (c) best research evidence; and (d) health care resources. Clinical judgement b
z% z% z% z% z% z% z% z% z% z% z% z% z%
ased on the nurse‘s clinical experience is part of EIP, but clinical decision making also
z% z% z% z% z% z% z% z% z% z% z% z% z% z% z%
should incorporate current research and research-
z% z% z% z% z%
based guidelines. Evidence from one clinical research study does not provide an adequat
z% z% z% z% z% z% z% z% z% z% z% z%
e substantiation for interventions. Evaluation of client outcomes is important, but interve
z% z% z% z% z% z% z% z% z% z% z%
ntions should be based on research from randomized control studies with a large numbe
z% z% z% z% z% z% z% z% z% z% z% z% z%
r of subjects.
z% z%
DIF: Cognitive Level: Comprehension z% z% TOP: z % Nursing Process: Planning z% z%
2. Which of the following best e xp l a i n s th e n u r s e s ‘ primary use of the nursing process
z%
N R I G B . C M
z% z% z% z% z% z% z% z% z% z% z% z% z% z % z% z% z% z% z%
when providing care to clients?
z% z%
USNT O z% z% z%
z% z% z%
a. To explain nursing interventions to other health care professionals
z% z% z% z% z% z% z% z%
b. As a problem-solving tool to identify and treat clients‘ health care needs
z% z% z% z% z% z% z% z% z% z% z%
c. As a scientific-based process of diagnosing the client‘s health care problems
z% z% z% z% z% z% z% z% z% z%
d. To establish nursing theory that incorporates the biopsychosocial nature of humans
z% z% z% z% z% z% z% z% z% z%
ANS: z % B
The nursing process is an assertive problem-
z% z% z% z% z% z%
solving approach to the identification and treatment of clients‘ problems. Diagnosis is on
z% z% z% z% z% z% z% z% z% z% z% z%
ly one phase of the nursing process. The primary use of the nursing process is in client
z% z% z% z% z% z% z% z% z% z% z% z% z% z% z% z% z%
care, not to establish nursing theory or explain nursing interventions to other health care
z% z% z% z% z% z% z% z% z% z% z% z% z% z%
professionals.
DIF: Cognitive Level: Comprehension z% z% TOP: z % Nursing Process: Implementation z% z%
3. The nurse is caring for a critically ill client in the intensive care unit and plans an every
z% z% z% z% z% z% z% z% z% z% z% z% z% z% z% z% z% z%
2-
hour turning schedule to prevent skin breakdown. Which type of nursing function is de
z% z% z% z% z% z% z% z% z% z% z% z% z%
monstrated with this turning schedule? z% z% z% z%
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: z % D
NURSINGTB.COM
, Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
z% z% z% z% z% z% z% z%
When implementing collaborative nursing actions, the nurse is responsible primarily for
z% z% z% z% z% z% z% z% z% z% z%
monitoring for complications of acute illness or providing care to prevent or treat compl
z% z% z% z% z% z% z% z% z% z% z% z% z%
ications. Independent nursing actions are focused on health promotion, illness prevention,
z% z% z% z% z% z% z% z% z% z%
and client advocacy. A dependent action would require a physician order to implement.
z% z% z% z% z% z% z% z% z% z% z% z% z% z
%Cooperative nursing functions are not described as one of the formal nursing functions.
z% z% z% z% z% z% z% z% z% z% z% z%
DIF: Cognitive Level: Application z% z% TOP: z % Nursing Process: Implementation
z% z%
4. The nurse is caring for a client who has been admitted to the hospital for surgery and te
z% z% z% z% z% z% z% z% z% z% z% z% z% z% z% z% z%
lls the nurse, ―I do not feel right about leaving my children with my neighbour.‖ Whi
z% z% z% z% z% z% z% z% z% z% z% z% z% z% z%
ch action should the nurse take next?
z% z% z% z% z% z%
a. Reassure the client that these feelings are common for parents.
z% z% z% z% z% z% z% z% z%
b. Have the client call the children to ensure that they are doing well.
z% z% z% z% z% z% z% z% z% z% z% z%
c. Call the neighbour to determine whether adequate childcare is being provided.
z% z% z% z% z% z% z% z% z% z%
d. Gather more data about the client‘s feelings about the childcare arrangements.
z% z% z% z% z% z% z% z% z% z%
ANS: z % D
Since a complete assessment is necessary in order to identify a problem and choose an
z% z% z% z% z% z% z% z% z% z% z% z% z% z% z%
appropriate intervention, the nurse‘s first action should be to obtain more information. T
z% z% z% z% z% z% z% z% z% z% z% z%
he other actions may be appropriate, but more assessment is needed before the best interv
z% z% z% z% z% z% z% z% z% z% z% z% z% z%
ention can be chosen.
z% z% z%
DIF: Cognitive Level: Application z% z% TOP: z % Nursing Process: Assessment z% z%
5. The nurse is caring for a client who has left-
z% z% z% z% z% z% z% z% z%
sided paralysis as the result of a stroke and assesses a pressure injury on the clie
nt‘s left h i p . W hich ofNtheRfollowing
I G isBthe
.CmostM appropriate nursing diagnosis f Uo r
z% z% z% z% z% z% z% z% z% z% z% z% z% z% z% z%
z % z % z % z % %
z %
z z %
z% z% z% %
z z% z% z% z% z% z% z% z% z% z% z% z% z% z% z
%t Sh i s cNl i e nTt ?
z% z% z% z% z% z% O z%
a. Impaired physical mobility related to decrease in muscle control (left-sided
z% z% z% z% z% z% z% z% z%
paralysis)
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge ab
z% z% z% z% z% z% z% z% z% z%
out protecting tissue integrity
z% z% z%
c. Impaired skin integrity related to pressure over bony prominence (impai
z% z% z% z% z% z% z% z% z%
red circulation)z%
d. Ineffective tissue perfusion related to sedentary lifestyle
z% z% z% z% z% z%
ANS: z % C
The client‘s major problem is the impaired skin integrity as demonstrated by the presence
z% z% z% z% z% z% z% z% z% z% z% z% z% z
%of a pressure injury. The nurse is able to treat the cause of altered circulation and press
z% z% z% z% z% z% z% z% z% z% z% z% z% z% z% z%
ure by frequently repositioning the client. Although left-
z% z% z% z% z% z% z%
sided weakness is a problem for the client, the nurse cannot treat the weakness. The ―ri
z% z% z% z% z% z% z% z% z% z% z% z% z% z% z%
sk for‖ diagnosis is not appropriate for this client, who already has impaired tissue integri
z% z% z% z% z% z% z% z% z% z% z% z% z% z%
ty. The client does have ineffective tissue perfusion, but the impaired skin integrity diag
z% z% z% z% z% z% z% z% z% z% z% z% z%
nosis indicates more clearly what the health problem is.
z% z% z% z% z% z% z% z%
DIF: Cognitive Level: Application z% z% TOP: z % Nursing Process: Diagnosis z% z%
6. The nurse caring for a client with an infection has a nursing diagnosis of deficient
z% z% z% z% z% z% z% z% z% z% z% z% z% z%
fluid volume related to excessive diaphoresis. Which of the following is an appro
z% z% z% z% z% z% z% z% z% z% z% z% z%
priate client outcome?
z% z%
a. Client has a balanced intake and output.
z% z% z% z% z% z%
b. Client‘s bedding is changed when it becomes damp.
z% z% z% z% z% z% z%
NURSINGTB.COM
, Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
z% z% z% z% z% z% z% z%
c. Client understands the need for increased fluid intake.
z% z% z% z% z% z% z%
d. Client‘s skin remains cool and dry throughout hospitalization.
z% z% z% z% z% z% z%
ANS: z % A
This statement gives measurable data showing resolution of the problem of deficient flui
z% z% z% z% z% z% z% z% z% z% z% z%
d volume that was identified in the nursing diagnosis statement. The other statements wou
z% z% z% z% z% z% z% z% z% z% z% z% z%
ld not indicate that the problem of deficient fluid volume was resolved.
z% z% z% z% z% z% z% z% z% z% z%
DIF: Cognitive Level: Application z% z% TOP: z % Nursing Process: Planning z% z%
7. Which of the following represents a nursing activity that is carried out during the evalu
z% z% z% z% z% z% z% z% z% z% z% z% z% z%
ation phase of the nursing process?
z% z% z% z% z%
a. Determining if interventions have been effective in meeting client outcomes
z% z% z% z% z% z% z% z% z%
b. Documenting the nursing care plan in the progress notes in the medical record
z% z% z% z% z% z% z% z% z% z% z% z%
c. Deciding whether the client‘s health problems have been completely resolved
z% z% z% z% z% z% z% z% z%
d. Asking the client to evaluate whether the nursing care provided was satisfactory
z% z% z% z% z% z% z% z% z% z% z%
ANS: z % A
Evaluation consists of determining whether the desired client outcomes have been met a
z% z% z% z% z% z% z% z% z% z% z% z%
nd whether the nursing interventions were appropriate. The other responses do not describ
z% z% z% z% z% z% z% z% z% z% z% z%
e the evaluation phase.
z% z% z%
DIF: Cognitive Level: Comprehension z% z% TOP: z % Nursing Process: Evaluationz% z%
8. Which of the following would the nurse perform during the assessment phase of the nu
z% z% z% z% z% z% z% z% z% z% z% z% z% z%
rsing process? z%
a. Obtains data with which to diagnose client problems
z% z% z% z% z% z% z%
b. Uses client data to develoNp p R riIt y nGursB
in.
gCdiagMnoses
z%
UriSo N T z%
c. Teaches interventions to relieve client health problems
z%
z% z%
z%
z%
z%
z% z% z%
z%
z% z %
z%
z%
z%
d. Assists the client to identify realistic outcomes to health problems
z% z% z% z% z% z% z% z% z%
ANS: z % A
During the assessment phase, the nurse gathers information about the client. The other r
z% z% z% z% z% z% z% z% z% z% z% z% z%
esponses are examples of the intervention, diagnosis, and planning phases of the nursing
z% z% z% z% z% z% z% z% z% z% z% z% z%
process.
DIF: Cognitive Level: Knowledge z% z% TOP: z % Nursing Process: Assessmentz% z%
9. Which of the following is an example of a correctly written nursing diagnosis statement?
z% z% z% z% z% z% z% z% z% z% z% z% z%
a. Altered tissue perfusion related to heart failure
z% z% z% z% z% z%
b. Risk for impaired tissue integrity related to sacral redness
z% z% z% z% z% z% z% z%
c. Ineffective coping related to insufficient sense of control.
z% z% z% z% z% z% z%
d. Altered urinary elimination related to urinary tract infection
z% z% z% z% z% z% z%
ANS: z % C
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that descr
z% z% z% z% z% z% z% z% z% z% z% z%
ibes a client‘s response to a health problem that can be treated by nursing. The use of
z% z% z% z% z% z% z% z% z% z% z% z% z% z% z% z% z
%a medical diagnosis (as in the responses beginning ―Altered tissue perfusion‖ and ―Alt
z% z% z% z% z% z% z% z% z% z% z% z%
ered urinary elimination‖) is not appropriate. The response beginning ―Risk for impaire
z% z% z% z% z% z% z% z% z% z% z%
d tissue integrity‖ uses the defining characteristics as the etiology.
z% z% z% z% z% z% z% z% z%
DIF: Cognitive Level: Comprehension z% z% TOP: z % Nursing Process: Diagnosis z% z%
NURSINGTB.COM
