Lewis's Medical-Surgical Nursing: Assessment and Management of
Clinical Problems 11th Edition TESTBANK
Table of Contents
Chapter 1. Professional Nursing
MULTIPLE CHOICE
1. The nurse completes an admission database and explains that the
plan of care and discharge goals will be developed with the patients
input. The patient states, how is this different from what 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 prescribed by your doctor.
b. The nurses 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 with the 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 describe some of the dependent and collaborative
functions of the nursing role but do not accurately describe the nurses 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 when caring 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
patient preferences.
ANS: D
Evidence-based practice (EBP) is the use of the best research-based
evidence combined with clinician expertise. Clinical judgment based on the
nurses 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 on
research from randomized control studies with a large number of subjects.
DIF: Cognitive Level: Remember (knowledge) REF: 11
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 providing patient 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 patients health 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 based on nursing theory that
incorporates the biopsychosocial nature of humans.
,d. The nursing process is used primarily to explain nursing
interventions to other health care professionals.
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 the nursing 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: 7
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 patients feelings about the
child-care arrangements.
d. Call the patients parents to determine whether adequate
child care is being provided.
ANS: C
Since a complete assessment is necessary in order to identify a problem
and choose an appropriate intervention, the nurses 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: Apply (application) REF: 6-7
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
, MSC: 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
d. Ineffective tissue perfusion related to inability to move independently
ANS: C
The patients major problem is the impaired skin integrity as demonstrated by
the presence of a pressure ulcer. The nurse is able to treat the cause of altered
circulation and pressure by frequently repositioning the patient. Although
left-sided weakness is a problem for the patient, the nurse cannot treat the
weakness. The risk for diagnosis is not appropriate for this patient, who
already has impaired tissue integrity. The patient does have ineffective tissue
perfusion, but the impaired skin integrity diagnosis indicates more clearly
what the health problem is.
DIF: Cognitive Level: Apply (application) REF: 7-9
TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity
6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid
volume related to excessive diaphoresis. Which outcome would the nurse
recognize as most appropriate for this patient?
a. Patient has a balanced intake and output.
b. Patients bedding is changed when it becomes damp.
c. Patient understands the need for increased fluid intake.
d. Patients skin remains cool and dry throughout hospitalization.
ANS: A
Clinical Problems 11th Edition TESTBANK
Table of Contents
Chapter 1. Professional Nursing
MULTIPLE CHOICE
1. The nurse completes an admission database and explains that the
plan of care and discharge goals will be developed with the patients
input. The patient states, how is this different from what 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 prescribed by your doctor.
b. The nurses 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 with the 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 describe some of the dependent and collaborative
functions of the nursing role but do not accurately describe the nurses 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 when caring 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
patient preferences.
ANS: D
Evidence-based practice (EBP) is the use of the best research-based
evidence combined with clinician expertise. Clinical judgment based on the
nurses 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 on
research from randomized control studies with a large number of subjects.
DIF: Cognitive Level: Remember (knowledge) REF: 11
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 providing patient 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 patients health 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 based on nursing theory that
incorporates the biopsychosocial nature of humans.
,d. The nursing process is used primarily to explain nursing
interventions to other health care professionals.
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 the nursing 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: 7
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 patients feelings about the
child-care arrangements.
d. Call the patients parents to determine whether adequate
child care is being provided.
ANS: C
Since a complete assessment is necessary in order to identify a problem
and choose an appropriate intervention, the nurses 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: Apply (application) REF: 6-7
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
, MSC: 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
d. Ineffective tissue perfusion related to inability to move independently
ANS: C
The patients major problem is the impaired skin integrity as demonstrated by
the presence of a pressure ulcer. The nurse is able to treat the cause of altered
circulation and pressure by frequently repositioning the patient. Although
left-sided weakness is a problem for the patient, the nurse cannot treat the
weakness. The risk for diagnosis is not appropriate for this patient, who
already has impaired tissue integrity. The patient does have ineffective tissue
perfusion, but the impaired skin integrity diagnosis indicates more clearly
what the health problem is.
DIF: Cognitive Level: Apply (application) REF: 7-9
TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity
6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid
volume related to excessive diaphoresis. Which outcome would the nurse
recognize as most appropriate for this patient?
a. Patient has a balanced intake and output.
b. Patients bedding is changed when it becomes damp.
c. Patient understands the need for increased fluid intake.
d. Patients skin remains cool and dry throughout hospitalization.
ANS: A
