Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
NURSINGTB.COM
, Medical-
Chapter 01: Introduction
Xi to Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
Xi Xi Xi
Surgical Nursing Practice in Canada Lewis: Medical-
Xi Xi Xi Xi Xi Xi
Surgical Nursing in Canada, 5th Canadian Edition
Xi Xi Xi Xi Xi Xi
MULTIPLE CHOICE Xi
1. When caring for clients using evidence-
Xi Xi Xi Xi Xi
informed practice, which of the following does the nurse use?
Xi Xi Xi Xi Xi Xi Xi Xi Xi
a. Clinical judgement based on experience Xi Xi Xi Xi
b. Evidence from a clinical research study Xi Xi Xi Xi Xi
c. The best available evidence to guide clinical expertise
Xi Xi Xi Xi Xi Xi Xi
d. Evaluation of data showing that the client outcomes are met Xi Xi Xi Xi Xi Xi Xi Xi Xi
ANS: X i C
Evidence-
informed nursing practice is a continuous interactive process involving the explicit, conscie
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ntious, and judicious consideration of the best available evidence to provide care. Four prim
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ary elements are: (a) clinical state, setting, and circumstances; (b) client preferences and act
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ions; (c) best research evidence; and (d) health care resources. Clinical judgement based on t
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
he nurse‘s clinical experience is part of EIP, but clinical decision making also should incor
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
porate current research and research-
Xi Xi Xi Xi
based guidelines. Evidence from one clinical research study does not provide an adequate s
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ubstantiation for interventions. Evaluation of client outcomes is important, but interventions
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
should be based on research from randomized control studies with a large number of subje
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
cts.
DIF: Cognitive Level: Comprehension Xi Xi TOP: X i Nursing Process: Planning Xi Xi
2. Which of the following best N
Xi e x p lRa i n sIt h eGn u B
Xi r s. ‘ prM
e sC
Xi imary use of the nursing process when Xi Xi Xi Xi Xi Xi Xi Xi Xi
providing care to clients USNT O
Xi Xi Xi Xi Xi Xi
?
a. To explain nursing interventions to other health care professionals
Xi Xi Xi Xi Xi Xi Xi Xi
b. As a problem-solving tool to identify and treat clients‘ health care needs
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
c. As a scientific-based process of diagnosing the client‘s health care problems
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
d. To establish nursing theory that incorporates the biopsychosocial nature of humans
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ANS: X i B
The nursing process is an assertive problem-
Xi Xi Xi Xi Xi Xi
solving approach to the identification and treatment of clients‘ problems. Diagnosis is only
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
one phase of the nursing process. The
Xi Xi Xi Xi Xi Xi
primary use of the nursing process is in client care, not to establish nursing theory or explai
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
n nursing interventions to other health care professionals.
Xi Xi Xi Xi Xi Xi Xi
DIF: Cognitive Level: Comprehension Xi Xi TOP: X i Nursing Process: Implementation
Xi Xi
3. The nurse is caring for a critically ill client in the intensive care unit and plans an every 2-
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
hour turning schedule to prevent skin breakdown. Which type of nursing function is demon
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
strated with this turning schedule?
Xi Xi Xi Xi
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: X i D
NURSINGTB.COM
, Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
When implementing collaborative nursing actions, the nurse is responsible primarily for mo
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
nitoring for complications of acute illness or providing care to prevent or treat complicatio
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ns. Independent nursing actions are focused on health promotion, illness prevention, and cli
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ent advocacy. A dependent action would require a physician order to implement. Cooperati
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ve nursing functions are not described as one of the formal nursing functions.
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
DIF: Cognitive Level: Application Xi Xi TOP: X i Nursing Process: Implementation Xi Xi
4. The nurse is caring for a client who has been admitted to the hospital for surgery and tells
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
the nurse, ―I do not feel right about leaving my children with my neighbour.‖ Which actio
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
n should the nurse take next?
Xi Xi Xi Xi Xi
a. Reassure the client that these feelings are common for parents.Xi Xi Xi Xi Xi Xi Xi Xi Xi
b. Have the client call the children to ensure that they are doing well.
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
c. Call the neighbour to determine whether adequate childcare is being provided.
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
d. Gather more data about the client‘s feelings about the childcare arrangements.
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ANS: X i D
Since a complete assessment is necessary in order to identify a problem and choose an appr
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
opriate intervention, the nurse‘s first action should be to obtain more information. The othe
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
r actions may be appropriate, but more assessment is needed before the best intervention can
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
be chosen.
Xi Xi
DIF: Cognitive Level: Application Xi Xi TOP: X i Nursing Process: Assessment Xi Xi
5. The nurse is caring for a client who has left-
Xi Xi Xi Xi Xi Xi Xi Xi Xi
sided paralysis as the result of a stroke and assesses a pressure injury on t h e cl i e nt ‘s
N R I
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
l eft h i p . W hich of the following is the most
G B. C M
Xi Xi Xi Xi Xi Xi Xi
appropriate nursing diagnosis fUo r t S
h i s cNl i e nTt ? O
Xi Xi Xi Xi Xi
a. Impaired physical mobility related to decrease in muscle control (left-
Xi Xi Xi Xi Xi Xi Xi Xi Xi
sided paralysis) Xi
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge abo
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ut protecting tissue integrity
Xi Xi Xi
c. Impaired skin integrity related to pressure over bony prominence (impaire
Xi Xi Xi Xi Xi Xi Xi Xi Xi
d circulation) Xi
d. Ineffective tissue perfusion related to sedentary lifestyle Xi Xi Xi Xi Xi Xi
ANS: X i C
The client‘s major problem is the impaired skin integrity as demonstrated by the presence of
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
a pressure injury. The nurse is able to treat the cause of altered circulation and pressure b
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
y frequently repositioning the client. Although left-
Xi Xi Xi Xi Xi Xi
sided weakness is a problem for the client,
Xi Xi Xi Xi Xi Xi Xi
the nurse cannot treat the weakness. The ―risk for‖ diagnosis is not appropriate for this clien
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
t, who already has impaired tissue integrity. The client does have ineffective tissue perfusio
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
n, but the impaired skin integrity diagnosis indicates more clearly what the health problem
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
is.
DIF: Cognitive Level: Application Xi Xi TOP: X i Nursing Process: Diagnosis Xi Xi
6. The nurse caring for a client with an infection has a nursing diagnosis of deficient fl
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
uid volume related to excessive diaphoresis. Which of the following is an appropriate
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
client outcome? Xi
a. Client has a balanced intake and output. Xi Xi Xi Xi Xi Xi
b. Client‘s bedding is changed when it becomes damp. Xi Xi Xi Xi Xi Xi Xi
NURSINGTB.COM
, Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
c. Client understands the need for increased fluid intake.
Xi Xi Xi Xi Xi Xi Xi
d. Client‘s skin remains cool and dry throughout hospitalization.
Xi Xi Xi Xi Xi Xi Xi
ANS: X i A
This statement gives measurable data showing resolution of the problem of deficient fluid v
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
olume that was identified in the nursing diagnosis statement. The other statements would not
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
indicate that the problem of deficient fluid volume was resolved.
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
DIF: Cognitive Level: Application Xi Xi TOP: X i Nursing Process: Planning Xi Xi
7. Which of the following represents a nursing activity that is carried out during the evaluati
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
on phase of the nursing process?
Xi Xi Xi Xi Xi
a. Determining if interventions have been effective in meeting client outcomes
Xi Xi Xi Xi Xi Xi Xi Xi Xi
b. Documenting the nursing care plan in the progress notes in the medical record Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
c. Deciding whether the client‘s health problems have been completely resolved
Xi Xi Xi Xi Xi Xi Xi Xi Xi
d. Asking the client to evaluate whether the nursing care provided was satisfactory
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ANS: X i A
Evaluation consists of determining whether the desired client outcomes have been met and
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
whether the nursing interventions were appropriate. The other responses do not describe the
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi X
evaluation phase.
i Xi
DIF: Cognitive Level: Comprehension Xi Xi TOP: X i Nursing Process: Evaluation Xi Xi
8. Which of the following would the nurse perform during the assessment phase of the nursi
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ng process?
Xi
a. Obtains data with which to diagnose client problems
Xi Xi Xi Xi Xi Xi Xi
b. Uses client data to develoNp pR
Xi
S NI
Urior y nGursB
i tT in.
gCdiagMnoses
O
c. Teaches interventions to relieve client health problems
Xi
Xi Xi Xi
Xi Xi
Xi
Xi Xi
Xi
Xi
Xi
Xi
Xi
Xi
d. Assists the client to identify realistic outcomes to health problems
Xi Xi Xi Xi Xi Xi Xi Xi Xi
ANS: X i A
During the assessment phase, the nurse gathers information about the client. The other resp
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
onses are examples of the intervention, diagnosis, and planning phases of the nursing proces
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
s.
DIF: Cognitive Level: Knowledge Xi Xi TOP: X i Nursing Process: Assessment Xi Xi
9. Which of the following is an example of a correctly written nursing diagnosis statement?
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
a. Altered tissue perfusion related to heart failure
Xi Xi Xi Xi Xi Xi
b. Risk for impaired tissue integrity related to sacral redness
Xi Xi Xi Xi Xi Xi Xi Xi
c. Ineffective coping related to insufficient sense of control.Xi Xi Xi Xi Xi Xi Xi
d. Altered urinary elimination related to urinary tract infection
Xi Xi Xi Xi Xi Xi Xi
ANS: X i C
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describ
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
es a client‘s response to a health problem that can be treated by nursing. The use of a med
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ical diagnosis (as in the responses beginning ―Altered tissue perfusion‖ and ―Altered urina
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ry
elimination‖) is not appropriate. The response beginning ―Risk for impaired tissue integrity‖
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
uses the defining characteristics as the etiology.
Xi Xi Xi Xi Xi Xi
DIF: Cognitive Level: Comprehension Xi Xi TOP: X i Nursing Process: Diagnosis Xi Xi
NURSINGTB.COM
Surgical Nursing in Canada 5th Edition Lewi Test Bank
NURSINGTB.COM
, Medical-
Chapter 01: Introduction
Xi to Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
Xi Xi Xi
Surgical Nursing Practice in Canada Lewis: Medical-
Xi Xi Xi Xi Xi Xi
Surgical Nursing in Canada, 5th Canadian Edition
Xi Xi Xi Xi Xi Xi
MULTIPLE CHOICE Xi
1. When caring for clients using evidence-
Xi Xi Xi Xi Xi
informed practice, which of the following does the nurse use?
Xi Xi Xi Xi Xi Xi Xi Xi Xi
a. Clinical judgement based on experience Xi Xi Xi Xi
b. Evidence from a clinical research study Xi Xi Xi Xi Xi
c. The best available evidence to guide clinical expertise
Xi Xi Xi Xi Xi Xi Xi
d. Evaluation of data showing that the client outcomes are met Xi Xi Xi Xi Xi Xi Xi Xi Xi
ANS: X i C
Evidence-
informed nursing practice is a continuous interactive process involving the explicit, conscie
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ntious, and judicious consideration of the best available evidence to provide care. Four prim
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ary elements are: (a) clinical state, setting, and circumstances; (b) client preferences and act
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ions; (c) best research evidence; and (d) health care resources. Clinical judgement based on t
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
he nurse‘s clinical experience is part of EIP, but clinical decision making also should incor
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
porate current research and research-
Xi Xi Xi Xi
based guidelines. Evidence from one clinical research study does not provide an adequate s
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ubstantiation for interventions. Evaluation of client outcomes is important, but interventions
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
should be based on research from randomized control studies with a large number of subje
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
cts.
DIF: Cognitive Level: Comprehension Xi Xi TOP: X i Nursing Process: Planning Xi Xi
2. Which of the following best N
Xi e x p lRa i n sIt h eGn u B
Xi r s. ‘ prM
e sC
Xi imary use of the nursing process when Xi Xi Xi Xi Xi Xi Xi Xi Xi
providing care to clients USNT O
Xi Xi Xi Xi Xi Xi
?
a. To explain nursing interventions to other health care professionals
Xi Xi Xi Xi Xi Xi Xi Xi
b. As a problem-solving tool to identify and treat clients‘ health care needs
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
c. As a scientific-based process of diagnosing the client‘s health care problems
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
d. To establish nursing theory that incorporates the biopsychosocial nature of humans
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ANS: X i B
The nursing process is an assertive problem-
Xi Xi Xi Xi Xi Xi
solving approach to the identification and treatment of clients‘ problems. Diagnosis is only
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
one phase of the nursing process. The
Xi Xi Xi Xi Xi Xi
primary use of the nursing process is in client care, not to establish nursing theory or explai
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
n nursing interventions to other health care professionals.
Xi Xi Xi Xi Xi Xi Xi
DIF: Cognitive Level: Comprehension Xi Xi TOP: X i Nursing Process: Implementation
Xi Xi
3. The nurse is caring for a critically ill client in the intensive care unit and plans an every 2-
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
hour turning schedule to prevent skin breakdown. Which type of nursing function is demon
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
strated with this turning schedule?
Xi Xi Xi Xi
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: X i D
NURSINGTB.COM
, Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
When implementing collaborative nursing actions, the nurse is responsible primarily for mo
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
nitoring for complications of acute illness or providing care to prevent or treat complicatio
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ns. Independent nursing actions are focused on health promotion, illness prevention, and cli
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ent advocacy. A dependent action would require a physician order to implement. Cooperati
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ve nursing functions are not described as one of the formal nursing functions.
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
DIF: Cognitive Level: Application Xi Xi TOP: X i Nursing Process: Implementation Xi Xi
4. The nurse is caring for a client who has been admitted to the hospital for surgery and tells
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
the nurse, ―I do not feel right about leaving my children with my neighbour.‖ Which actio
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
n should the nurse take next?
Xi Xi Xi Xi Xi
a. Reassure the client that these feelings are common for parents.Xi Xi Xi Xi Xi Xi Xi Xi Xi
b. Have the client call the children to ensure that they are doing well.
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
c. Call the neighbour to determine whether adequate childcare is being provided.
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
d. Gather more data about the client‘s feelings about the childcare arrangements.
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ANS: X i D
Since a complete assessment is necessary in order to identify a problem and choose an appr
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
opriate intervention, the nurse‘s first action should be to obtain more information. The othe
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
r actions may be appropriate, but more assessment is needed before the best intervention can
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
be chosen.
Xi Xi
DIF: Cognitive Level: Application Xi Xi TOP: X i Nursing Process: Assessment Xi Xi
5. The nurse is caring for a client who has left-
Xi Xi Xi Xi Xi Xi Xi Xi Xi
sided paralysis as the result of a stroke and assesses a pressure injury on t h e cl i e nt ‘s
N R I
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
l eft h i p . W hich of the following is the most
G B. C M
Xi Xi Xi Xi Xi Xi Xi
appropriate nursing diagnosis fUo r t S
h i s cNl i e nTt ? O
Xi Xi Xi Xi Xi
a. Impaired physical mobility related to decrease in muscle control (left-
Xi Xi Xi Xi Xi Xi Xi Xi Xi
sided paralysis) Xi
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge abo
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ut protecting tissue integrity
Xi Xi Xi
c. Impaired skin integrity related to pressure over bony prominence (impaire
Xi Xi Xi Xi Xi Xi Xi Xi Xi
d circulation) Xi
d. Ineffective tissue perfusion related to sedentary lifestyle Xi Xi Xi Xi Xi Xi
ANS: X i C
The client‘s major problem is the impaired skin integrity as demonstrated by the presence of
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
a pressure injury. The nurse is able to treat the cause of altered circulation and pressure b
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
y frequently repositioning the client. Although left-
Xi Xi Xi Xi Xi Xi
sided weakness is a problem for the client,
Xi Xi Xi Xi Xi Xi Xi
the nurse cannot treat the weakness. The ―risk for‖ diagnosis is not appropriate for this clien
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
t, who already has impaired tissue integrity. The client does have ineffective tissue perfusio
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
n, but the impaired skin integrity diagnosis indicates more clearly what the health problem
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
is.
DIF: Cognitive Level: Application Xi Xi TOP: X i Nursing Process: Diagnosis Xi Xi
6. The nurse caring for a client with an infection has a nursing diagnosis of deficient fl
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
uid volume related to excessive diaphoresis. Which of the following is an appropriate
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
client outcome? Xi
a. Client has a balanced intake and output. Xi Xi Xi Xi Xi Xi
b. Client‘s bedding is changed when it becomes damp. Xi Xi Xi Xi Xi Xi Xi
NURSINGTB.COM
, Medical-
Surgical Nursing in Canada 5th Edition Lewi Test Bank
c. Client understands the need for increased fluid intake.
Xi Xi Xi Xi Xi Xi Xi
d. Client‘s skin remains cool and dry throughout hospitalization.
Xi Xi Xi Xi Xi Xi Xi
ANS: X i A
This statement gives measurable data showing resolution of the problem of deficient fluid v
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
olume that was identified in the nursing diagnosis statement. The other statements would not
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
indicate that the problem of deficient fluid volume was resolved.
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
DIF: Cognitive Level: Application Xi Xi TOP: X i Nursing Process: Planning Xi Xi
7. Which of the following represents a nursing activity that is carried out during the evaluati
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
on phase of the nursing process?
Xi Xi Xi Xi Xi
a. Determining if interventions have been effective in meeting client outcomes
Xi Xi Xi Xi Xi Xi Xi Xi Xi
b. Documenting the nursing care plan in the progress notes in the medical record Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
c. Deciding whether the client‘s health problems have been completely resolved
Xi Xi Xi Xi Xi Xi Xi Xi Xi
d. Asking the client to evaluate whether the nursing care provided was satisfactory
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ANS: X i A
Evaluation consists of determining whether the desired client outcomes have been met and
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
whether the nursing interventions were appropriate. The other responses do not describe the
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi X
evaluation phase.
i Xi
DIF: Cognitive Level: Comprehension Xi Xi TOP: X i Nursing Process: Evaluation Xi Xi
8. Which of the following would the nurse perform during the assessment phase of the nursi
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ng process?
Xi
a. Obtains data with which to diagnose client problems
Xi Xi Xi Xi Xi Xi Xi
b. Uses client data to develoNp pR
Xi
S NI
Urior y nGursB
i tT in.
gCdiagMnoses
O
c. Teaches interventions to relieve client health problems
Xi
Xi Xi Xi
Xi Xi
Xi
Xi Xi
Xi
Xi
Xi
Xi
Xi
Xi
d. Assists the client to identify realistic outcomes to health problems
Xi Xi Xi Xi Xi Xi Xi Xi Xi
ANS: X i A
During the assessment phase, the nurse gathers information about the client. The other resp
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
onses are examples of the intervention, diagnosis, and planning phases of the nursing proces
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
s.
DIF: Cognitive Level: Knowledge Xi Xi TOP: X i Nursing Process: Assessment Xi Xi
9. Which of the following is an example of a correctly written nursing diagnosis statement?
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
a. Altered tissue perfusion related to heart failure
Xi Xi Xi Xi Xi Xi
b. Risk for impaired tissue integrity related to sacral redness
Xi Xi Xi Xi Xi Xi Xi Xi
c. Ineffective coping related to insufficient sense of control.Xi Xi Xi Xi Xi Xi Xi
d. Altered urinary elimination related to urinary tract infection
Xi Xi Xi Xi Xi Xi Xi
ANS: X i C
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describ
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
es a client‘s response to a health problem that can be treated by nursing. The use of a med
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ical diagnosis (as in the responses beginning ―Altered tissue perfusion‖ and ―Altered urina
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
ry
elimination‖) is not appropriate. The response beginning ―Risk for impaired tissue integrity‖
Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi Xi
uses the defining characteristics as the etiology.
Xi Xi Xi Xi Xi Xi
DIF: Cognitive Level: Comprehension Xi Xi TOP: X i Nursing Process: Diagnosis Xi Xi
NURSINGTB.COM
