Test Bank for Lewis's Medical-Surgical
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Nursing, 12th Edition by Mariann M. Har
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ding, Jeffrey Kwong, Debra Hagler Chapte
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r 1-69
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,Chapter 01: Professional Nursing
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Harding: Lewis’s Medical-Surgical Nursing, 12th Edition
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MULTIPLE CHOICE df
1. The nurse completes an admission database and explains that the plan of care and discharg
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e goals will be developed with the patient‘s input. The patient asks, “How is this different fro
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m what the physician does?” Which response would the nurse provide?
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a. “The role of the nurse is to administer medications and other treatments prescribed
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by your physician.” df df
b. “In addition to caring for you while you are sick, the nurses will help you plan to
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maintain your health.” df df
c. “The nurse‘s job is to collect information and communicate any problems that
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occur to the physician.” df df df
d. “Nurses perform many of the same procedures as the physician, but nurses are
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with the patients for a longer time than the physician.”
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ANS: B df
The American Nurses Association (ANA) definition of nursing describes the role of nurses in
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promoting health. The other responses describe dependent and collaborative functions of th
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e nursing role but do not accurately describe the nurse‘s unique role in the health care syste
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m.
DIF: Cognitive Level: Analyze (Analysis)
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TOP: Nursing Process: Implementation
d f df df d f d f d f MSC: NCLEX: Safe and Effective Care Environment
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2. Which statement by the nurse accurately describes the use of evidence-based practice (EBP)?
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a. “Patient care is based on clinical judgment, experience, and traditions.”
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b. “Data are analyzed later to show that the patient outcomes are consistently met.”
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c. “Research from all published articles are used as a guide for planning patient care.”
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d. “Recommendations are based on research, clinical expertise, and patient df df df df df df df df df
preferences.”
ANS: D df
Evidence-based practice (EBP) is the use of the best research- df df df df df df df df df
based evidence combined with clinician expertise and consideration of patient preferences.
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Clinical judgment based on the nurse‘s clinical experience is part of EBP, but clinical decis
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ion making should also incorporate current research and research-
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based guidelines. Evaluation of patient outcomes is important, but data analysis is not require
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d to use EBP. All published articles do not provide research evidence; interventions should b
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e based on credible research, preferably randomized controlled studies with a large number o
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f subjects.
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DIF: Cognitive Level: Understand (Comprehension) df df df
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
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3. Which statement by the nurse provides a clear explanation of the nursing process?
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a. “The nursing process is a research method of diagnosing the patient‘s health care
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problems.”
b. “The nursing process is used primarily to explain nursing interventions to other
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health care professionals.” df df
c. “The nursing process is a problem-solving tool used to identify and manage the
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, patients‘ health care needs.” df df df
d. “The nursing process is based on nursing theory that incorporates the
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f biopsychosocial nature of humans.” df df df
ANS: C df
The nursing process is a problem-
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solving approach to the identification and treatment of patients‘ problems. Nursing process
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does not require research methods for diagnosis. The primary use of the nursing process is in
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patient care, not to establish nursing theory or explain nursing interventions to other health c
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are professionals.
df
DIF: Cognitive Level: Understand (Comprehension) df df df
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
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4. A patient admitted to the hospital for surgery tells the nurse, “I do not feel comfortable
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leaving my children with my parents.” Which action would the nurse take next?
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a. Reassure the patient that these feelings are common for parents.
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b. Have the patient call the children to ensure that they are doing well.
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c. Gather information on the patient‘s concerns about the child care arrangements.
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d. Call the patient‘s parents to determine whether adequate child care is being
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provided.
ANS: C df
Because a complete assessment is necessary in order to identify a problem and choose an a
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ppropriate intervention, the nurse‘s first action should be to obtain more information. The o
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ther actions may be appropriate, but more assessment is needed before the best intervention ca
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n be chosen.
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DIF: Cognitive Level: Analyze (Analysis) df df df
TOP: Nursing Process: Assessment
d f MSC: NCLEX: Psychosocial Integrity
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5. A patient with a bacterial infection is hypovolemic due to a fever and excessive diaphoresis.
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Which expected outcome would the nurse select for this patient?
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a. Patient has a balanced intake and output. df df df df df df
b. Patient‘s bedding is kept clean and free of moisture. df df df df df df df df
c. Patient understands the need for increased fluid intake.
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d. Patient‘s skin remains cool and dry throughout hospitalization.
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ANS: A df
Balanced intake and output gives measurable data showing resolution of the problem of defici
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ent fluid volume. The other statements would not indicate that the problem of hypovolemia
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was resolved.
f df
DIF: Cognitive Level: Apply (Application) df df df
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
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6. Which statement describes the purpose of the evaluation phase of the nursing process?
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a. To document the nursing care plan in the progress notes of the health record
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b. To determine if interventions have been effective in meeting patient outcomes
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c. To decide whether the patient‘s health problems have been completely resolved
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d. To establish if the patient agrees that the nursing care provided was satisfactory
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ANS: B df
, Evaluation consists of determining whether the desired patient outcomes have been met and
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whether the nursing interventions were appropriate. The other responses do not describe th
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e evaluation phase.
df df
DIF: Cognitive Level: Understand (Comprehension) df df df
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
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7. Which statement describes the purpose of the assessment phase of the nursing process?
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a. To teach interventions that relieve health problems
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b. To use patient data to evaluate patient care outcomes
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c. To obtain data to diagnose patient strengths and problems
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d. To help the patient identify realistic outcomes for health problems
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ANS: C df
During the assessment phase, the nurse gathers information about the patient to diagnose patie
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nt strengths and problems. The other responses are examples of the planning, intervention,
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and evaluation phases of the nursing process.
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DIF: Cognitive Level: Understand (Comprehension) df df df
TOP: Nursing Process: Assessment
d f MSC: NCLEX: Safe and Effective Care Environment
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8. When developing the plan of care, which components would the nurse include in the clinical
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problem statement? df
a. The problem and the suggested patient goals or outcomes
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b. The problem, its causes, and the signs and symptoms of the problem
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c. The problem with the possible etiology and the planned interventions
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d. The problem, its pathophysiology, and the expected outcome
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ANS: B df
When writing clinical problems or nursing diagnoses, the subjective as well as objective dat
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a to support the problem‘s existence should be included. Goals, outcomes, and interventions ar
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e not included in the problem statement.
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DIF: Cognitive Level: Understand (Comprehension) df df df
TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment
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9. Which patient care task would the nurse delegate to experienced assistive personnel (AP)?
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a. Instruct the patient about the need to alternate activity and rest.
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b. Monitor level of shortness of breath or fatigue after ambulation.
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c. Obtain the patient‘s blood pressure and pulse rate after ambulation.
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d. Determine whether the patient is ready to increase the activity level.
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ANS: C df
AP education includes accurate vital sign measurement. Assessment and patient teaching requi
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re registered nurse education and scope of practice and cannot be delegated.
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DIF: Cognitive Level: Apply (Application) df df df
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
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df df df df
Nursing, 12th Edition by Mariann M. Har
df df df df df df
ding, Jeffrey Kwong, Debra Hagler Chapte
df df df df df
r 1-69
df
,Chapter 01: Professional Nursing
df df df
Harding: Lewis’s Medical-Surgical Nursing, 12th Edition
df df df df df
MULTIPLE CHOICE df
1. The nurse completes an admission database and explains that the plan of care and discharg
df df df df df df df df df df df df df df
e goals will be developed with the patient‘s input. The patient asks, “How is this different fro
df df df df df df df df df df df df df df df df
m what the physician does?” Which response would the nurse provide?
df df df df df df df df df df
a. “The role of the nurse is to administer medications and other treatments prescribed
df df df df df df df df df df df df df
by your physician.” df df
b. “In addition to caring for you while you are sick, the nurses will help you plan to
df df df df df df df df df df df df df df df df df
maintain your health.” df df
c. “The nurse‘s job is to collect information and communicate any problems that
df df df df df df df df df df df df
occur to the physician.” df df df
d. “Nurses perform many of the same procedures as the physician, but nurses are
df df df df df df df df df df df df df
with the patients for a longer time than the physician.”
df df df df df df df df df
ANS: B df
The American Nurses Association (ANA) definition of nursing describes the role of nurses in
df df df df df df df df df df df df df df
promoting health. The other responses describe dependent and collaborative functions of th
df df df df df df df df df df df
e nursing role but do not accurately describe the nurse‘s unique role in the health care syste
df df df df df df df df df df df df df df df df
m.
DIF: Cognitive Level: Analyze (Analysis)
d f d f df df df
TOP: Nursing Process: Implementation
d f df df d f d f d f MSC: NCLEX: Safe and Effective Care Environment
d f df df df df df
2. Which statement by the nurse accurately describes the use of evidence-based practice (EBP)?
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a. “Patient care is based on clinical judgment, experience, and traditions.”
df df df df df df df df df
b. “Data are analyzed later to show that the patient outcomes are consistently met.”
df df df df df df df df df df df df
c. “Research from all published articles are used as a guide for planning patient care.”
df df df df df df df df df df df df df
d. “Recommendations are based on research, clinical expertise, and patient df df df df df df df df df
preferences.”
ANS: D df
Evidence-based practice (EBP) is the use of the best research- df df df df df df df df df
based evidence combined with clinician expertise and consideration of patient preferences.
df df df df df df df df df df df
Clinical judgment based on the nurse‘s clinical experience is part of EBP, but clinical decis
df df df df df df df df df df df df df df
ion making should also incorporate current research and research-
df df df df df df df df
based guidelines. Evaluation of patient outcomes is important, but data analysis is not require
df df df df df df df df df df df df df
d to use EBP. All published articles do not provide research evidence; interventions should b
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e based on credible research, preferably randomized controlled studies with a large number o
df df df df df df df df df df df df df
f subjects.
df
DIF: Cognitive Level: Understand (Comprehension) df df df
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
df df df df d f df df df df df
3. Which statement by the nurse provides a clear explanation of the nursing process?
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a. “The nursing process is a research method of diagnosing the patient‘s health care
df df df df df df df df df df df df df
problems.”
b. “The nursing process is used primarily to explain nursing interventions to other
df df df df df df df df df df df df
health care professionals.” df df
c. “The nursing process is a problem-solving tool used to identify and manage the
df df df df df df df df df df df df
, patients‘ health care needs.” df df df
d. “The nursing process is based on nursing theory that incorporates the
df df df df df df df df df df d
f biopsychosocial nature of humans.” df df df
ANS: C df
The nursing process is a problem-
df df df df df
solving approach to the identification and treatment of patients‘ problems. Nursing process
df df df df df df df df df df df df
does not require research methods for diagnosis. The primary use of the nursing process is in
df df df df df df df df df df df df df df df df
patient care, not to establish nursing theory or explain nursing interventions to other health c
df df df df df df df df df df df df df df
are professionals.
df
DIF: Cognitive Level: Understand (Comprehension) df df df
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
df df df df d f df df df df df
4. A patient admitted to the hospital for surgery tells the nurse, “I do not feel comfortable
df df df df df df df df df df df df df df df df
leaving my children with my parents.” Which action would the nurse take next?
df df df df df df df df df df df df
a. Reassure the patient that these feelings are common for parents.
df df df df df df df df df
b. Have the patient call the children to ensure that they are doing well.
df df df df df df df df df df df df
c. Gather information on the patient‘s concerns about the child care arrangements.
df df df df df df df df df df
d. Call the patient‘s parents to determine whether adequate child care is being
df df df df df df df df df df df df
provided.
ANS: C df
Because a complete assessment is necessary in order to identify a problem and choose an a
df df df df df df df df df df df df df df df
ppropriate intervention, the nurse‘s first action should be to obtain more information. The o
df df df df df df df df df df df df df
ther actions may be appropriate, but more assessment is needed before the best intervention ca
df df df df df df df df df df df df df df
n be chosen.
df df
DIF: Cognitive Level: Analyze (Analysis) df df df
TOP: Nursing Process: Assessment
d f MSC: NCLEX: Psychosocial Integrity
df df d f df df
5. A patient with a bacterial infection is hypovolemic due to a fever and excessive diaphoresis.
df df df df df df df df df df df df df df d
Which expected outcome would the nurse select for this patient?
f df df df df df df df df df
a. Patient has a balanced intake and output. df df df df df df
b. Patient‘s bedding is kept clean and free of moisture. df df df df df df df df
c. Patient understands the need for increased fluid intake.
df df df df df df df
d. Patient‘s skin remains cool and dry throughout hospitalization.
df df df df df df df
ANS: A df
Balanced intake and output gives measurable data showing resolution of the problem of defici
df df df df df df df df df df df df df
ent fluid volume. The other statements would not indicate that the problem of hypovolemia
df df df df df df df df df df df df df d
was resolved.
f df
DIF: Cognitive Level: Apply (Application) df df df
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
df df df df d f df df
6. Which statement describes the purpose of the evaluation phase of the nursing process?
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a. To document the nursing care plan in the progress notes of the health record
df df df df df df df df df df df df df
b. To determine if interventions have been effective in meeting patient outcomes
df df df df df df df df df df
c. To decide whether the patient‘s health problems have been completely resolved
df df df df df df df df d f df
d. To establish if the patient agrees that the nursing care provided was satisfactory
df df df df df df df df df df df df
ANS: B df
, Evaluation consists of determining whether the desired patient outcomes have been met and
df df df df df df df df df df df df
whether the nursing interventions were appropriate. The other responses do not describe th
df df df df df df df df df df df df df
e evaluation phase.
df df
DIF: Cognitive Level: Understand (Comprehension) df df df
TOP: Nursing Process: Evaluation MSC: NCLEX: Safe and Effective Care Environment
df df df df d f df df df df df
7. Which statement describes the purpose of the assessment phase of the nursing process?
df df df df df df df df df df df df
a. To teach interventions that relieve health problems
df df df df df df
b. To use patient data to evaluate patient care outcomes
df df df df df df df df
c. To obtain data to diagnose patient strengths and problems
df df df df df df df df
d. To help the patient identify realistic outcomes for health problems
df df df df df df df df df
ANS: C df
During the assessment phase, the nurse gathers information about the patient to diagnose patie
df df df df df df df df df df df df df
nt strengths and problems. The other responses are examples of the planning, intervention,
df df df df df df df df df df df df df
and evaluation phases of the nursing process.
df df df df df df
DIF: Cognitive Level: Understand (Comprehension) df df df
TOP: Nursing Process: Assessment
d f MSC: NCLEX: Safe and Effective Care Environment
df df d f df df df df df
8. When developing the plan of care, which components would the nurse include in the clinical
df df df df df df df df df df df df df df df
problem statement? df
a. The problem and the suggested patient goals or outcomes
df df df df df df df df
b. The problem, its causes, and the signs and symptoms of the problem
df df df df df df df df df df df
c. The problem with the possible etiology and the planned interventions
df df df df df df df df df
d. The problem, its pathophysiology, and the expected outcome
df df df df df df df
ANS: B df
When writing clinical problems or nursing diagnoses, the subjective as well as objective dat
df df df df df df df df df df df df df
a to support the problem‘s existence should be included. Goals, outcomes, and interventions ar
df df df df df df df df df df df df df
e not included in the problem statement.
df df df df df df
DIF: Cognitive Level: Understand (Comprehension) df df df
TOP: Nursing Process: Diagnosis MSC: NCLEX: Safe and Effective Care Environment
df df df df d f df df df df df
9. Which patient care task would the nurse delegate to experienced assistive personnel (AP)?
df df df df df df df df df df df df
a. Instruct the patient about the need to alternate activity and rest.
df df df df df df df df df df
b. Monitor level of shortness of breath or fatigue after ambulation.
df df df df df df df df df
c. Obtain the patient‘s blood pressure and pulse rate after ambulation.
df df df df df df df df df
d. Determine whether the patient is ready to increase the activity level.
df df df d f df df df df df df
ANS: C df
AP education includes accurate vital sign measurement. Assessment and patient teaching requi
df df df df df df df df df df df
re registered nurse education and scope of practice and cannot be delegated.
df df df df df df df df df df df
DIF: Cognitive Level: Apply (Application) df df df
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
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