TEST BANK
Medical-Surgical Nursing in Canada
Sharon Lewis Margaret McLean Heitkemper Linda Bucher
4th Edition
TEST BANK
,Table of content
l Introduction to Medical-Surgical Nursing Practice in Canada
2 Cultural Competence and Health Equity in Nursing Care
3 Health History and Physical Examination
4 Patient and Caregiver Teaching
5 Chronic Illness
6 Community-Based Nursing and Home Care
7 Older Adults
8 Stress and Stress Management
9 Sleep and Sleep
Disorders I0 Pain
11 Substance Use
12 Complementary and Alternative Therapies
13 Palliative Care at the End of Life
14 Inflammation and Wound Healing
15 Genetics
16 Altered Immune Response and Transplantation
17 Infection and Human Immunodeficiency Virus Infection
18 Cancer
19 Fluid, Electrolyte, and Acid-Base Imbalances
20: Nursing Management: Preoperative Care
21: Nursing Management: Intraoperative Care
22: Nursing Management: Postoperative Care
23: Nursing Assessment: Visual and Auditory Systems
24: Nursing Management: Visual and Auditory Problems
25: Nursing Assessment: Integumentary System
26: Nursing Management: Integumentary Problems
27: Nursing Management: Burns
28: Nursing Assessment: Respiratory System
29: Nursing Management: Upper Respiratory Problems
30: Nursing Management: Lower Respiratory Problems
31: Nursing Management: Obstructive Pulmonary Diseases
32: Nursing Assessment: Hematological System
33: Nursing Management: Hematological Problems
34: Nursing Assessment: Cardiovascular System
35: Nursing Management: Hypertension
36: Nursing Management: Coronary Artery Disease and Acute Coronary
Syndrome
37: Nursing Management: Heart Failure
38: Nursing Management: Dysrhythmias
39: Nursing Management: Inflammatory and Structural Heart Disorders
40: Nursing Management: Vascular Disorders
41: Nursing Assessment: Gastro-intestinal System
42: Nursing Management: Nutritional Problems
43: Nursing Management: Obesity
44: Nursing Management: Upper Gastro-intestinal Problems
45: Nursing Management: Lower Gastro-intestinal Problems
46: Nursing Management: Liver, Pancreas, and Biliary Tract Problems
47: Nursing Management: Urinary System
,48: Nursing Management: Renal and Urological Problems
49: Nursing Management: Acute Kidney Injury and Chronic Kidney
Disease
50: Nursing Assessment: Endocrine System
51: Nursing Management: Endocrine Problems
52: Nursing Management: Diabetes Mellitus
53: Nursing Assessment: Reproductive System
54: Nursing Management: Breast Disorders
55: Nursing Management: Sexually Transmitted Infections
56: Nursing Management: Female Reproductive Problems
57: Nursing Management: Male Reproductive Problems
58: Nursing Assessment: Nervous System
59: Nursing Management: Acute Intracranial Problems
60: Nursing Management: Stroke
61: Nursing Management: Chronic Neurological Problems
62: Nursing Management: Delirium, Alzheimer's Disease, and Other
Dementias
63: Nursing Management: Peripheral Nerve and Spinal Cord Problems
64: Nursing Assessment: Musculo-skeletal System
65: Nursing Management: Musculo-skeletal Trauma and Orthopedic
Surgery
66: Nursing Management: Musculo-Skeletal Problems
67: Nursing Management: Arthritis and Connective Tissue Diseases
68: Nursing Management: Critical Care Environment
69: Nursing Management: Shock, Systemic Inflammatory Response
Syndrome, and Multiple-Organ Dysfunction Syndrome
70: Nursing Management: Respiratory Failure and Acute Respiratory
Distress Syndrome
71: Nursing Management: Emergency Care Situations
72: Emergency Management and Disaster Planning
,Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada
Lewis: Medical-Surgical Nursing in Canada, 4th 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,
conscientious, 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 nurse’s clinical experience is part of EIP, but clinical decision making also should
incorporate current research and research-based guidelines. Evidence from one clinical
research study does not provide an adequate substantiation for interventions. Evaluation of
client outcomes is important, but interventions should 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 eNxp lR
ainsIt heGnu B
r se.s’Cp r iMmar y use of the nursing process when
providing care to clients? U S N T 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 demonstrated
with this turning schedule?
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: D
, When fimplementing fcollaborative fnursing factions, fthe fnurse fis fresponsible fprimarily ffor
f monitoring f for fcomplications fof facute f illness for fproviding fcare fto fprevent for ftreat
fcomplications. fIndependent fnursing factions fare f focused fon f health fpromotion, f illness
fprevention, fand fclient fadvocacy. f A fdependent faction fwould frequire fa fphysician forder
fto fimplement. fCooperative fnursing ffunctions fare fnot fdescribed fas fone fof fthe fformal
fnursing f functions.
DIF: Cognitive fLevel: fApplication TOP: f Nursing fProcess: fImplementation
4. The fnurse fis fcaring ffor fa fclient fwho fhas fbeen fadmitted fto fthe fhospital ffor fsurgery fand
ftells fthe f nurse, f“I fdo fnot ffeel fright fabout fleaving f my fchildren fwith f my f neighbour.”
fWhich faction fshould fthe f nurse ftake fnext?
a. Reassure fthe fclient fthat fthese ffeelings fare fcommon ffor fparents.
b. Have fthe fclient fcall fthe fchildren fto fensure fthat fthey fare fdoing fwell.
c. Call fthe fneighbour fto fdetermine fwhether fadequate fchildcare fis fbeing fprovided.
d. Gather fmore fdata fabout fthe fclient’s ffeelings fabout fthe fchildcare farrangements.
ANS: f D
Since fa fcomplete fassessment fis fnecessary fin forder fto fidentify fa fproblem fand fchoose
fan fappropriate f intervention, fthe fnurse’s f first faction fshould f be fto fobtain f more
f information. fThe fother factions fmay fbe fappropriate, fbut fmore fassessment fis fneeded
fbefore fthe fbest fintervention fcan f be fchosen.
DIF: Cognitive fLevel: fApplication TOP: f Nursing fProcess: fAssessment
5. The fnurse fis fcaring ffor fa fclient fwho fhas fleft-sided fparalysis fas fthe fresult fof fa fstroke fand
assesses fa fpressure f injury fon the f c l i e nt ’ s l e ft h i p . fW hich fof fthe ffollowing fis fthe fmost
appropriate f nursing fdiagnosisNf fUoRr ft S hIi s f cN
Gl i e nB
Tt ?. C MO
a. Impaired fphysical fmobility frelated fto fdecrease fin fmuscle fcontrol f(left-
sided fparalysis)
b. Risk ffor fimpaired ftissue fintegrity fas fevidenced fby finsufficient fknowledge
fabout fprotecting ftissue f integrity
c. Impaired fskin fintegrity frelated fto fpressure fover fbony fprominence
f(impaired fcirculation)
d. Ineffective ftissue fperfusion frelated fto fsedentary flifestyle
ANS: f C
The fclient’s fmajor fproblem fis fthe fimpaired fskin fintegrity fas fdemonstrated fby fthe
fpresence fof fa fpressure f injury. fThe f nurse f is fable fto ftreat fthe fcause fof faltered
fcirculation fand fpressure f by f frequently frepositioning fthe fclient. fAlthough f left-sided
fweakness f is fa fproblem f for fthe fclient, fthe fnurse fcannot ftreat fthe fweakness. fThe f “risk
f for” fdiagnosis f is fnot fappropriate f for fthis fclient, fwho falready f has f impaired ftissue
f integrity. fThe fclient fdoes fhave f ineffective ftissue fperfusion, f but fthe f impaired fskin
f integrity fdiagnosis f indicates f more fclearly fwhat fthe fhealth fproblem f is.
DIF: Cognitive fLevel: fApplication TOP: f Nursing fProcess: fDiagnosis
6. The fnurse fcaring ffor fa fclient fwith fan finfection fhas fa fnursing fdiagnosis fof
fdeficient ffluid f volume frelated fto fexcessive fdiaphoresis. fWhich fof fthe ffollowing fis
fan fappropriate fclient foutcome?
a. Client fhas fa fbalanced fintake fand foutput.
b. Client’s fbedding fis fchanged fwhen fit fbecomes fdamp.
, c. Client funderstands fthe fneed ffor fincreased ffluid fintake.
d. Client’s fskin fremains fcool fand fdry fthroughout fhospitalization.
ANS: f A
This fstatement fgives fmeasurable fdata fshowing fresolution fof fthe fproblem fof fdeficient
f fluid fvolume fthat fwas fidentified fin fthe fnursing fdiagnosis fstatement. fThe fother
fstatements fwould fnot findicate fthat fthe fproblem fof fdeficient ffluid f volume fwas fresolved.
DIF: Cognitive fLevel: fApplication TOP: f Nursing fProcess: fPlanning
7. Which fof fthe ffollowing frepresents fa fnursing factivity fthat fis fcarried fout fduring fthe
fevaluation fphase fof fthe f nursing fprocess?
a. Determining fif finterventions fhave fbeen feffective fin fmeeting fclient foutcomes
b. Documenting fthe fnursing fcare fplan fin fthe fprogress fnotes fin fthe fmedical frecord
c. Deciding fwhether fthe fclient’s fhealth fproblems fhave fbeen fcompletely fresolved
d. Asking fthe fclient fto fevaluate fwhether fthe fnursing fcare fprovided fwas fsatisfactory
ANS: f A
Evaluation fconsists fof fdetermining fwhether fthe fdesired fclient foutcomes fhave fbeen fmet
fand fwhether fthe fnursing finterventions fwere fappropriate. fThe fother fresponses fdo fnot
fdescribe fthe fevaluation fphase.
DIF: Cognitive fLevel: fComprehension TOP: f Nursing fProcess: fEvaluation
8. Which fof fthe ffollowing fwould fthe fnurse fperform fduring fthe fassessment fphase fof fthe
fnursing fprocess?
a. Obtains fdata fwith fwhich fto fdiagnose fclient fproblems
b. Uses fclient fdata fto fdeveloNp fp Rior iIt y f nGursiBng.dCiagM
c. U rS
Teaches finterventions fto frelieve N T O noses
fclient fhealth fproblems
d. Assists fthe fclient fto fidentify frealistic foutcomes fto fhealth fproblems
ANS: f A
During fthe fassessment fphase, fthe fnurse fgathers finformation fabout fthe fclient. fThe fother
fresponses fare fexamples fof fthe fintervention, fdiagnosis, fand fplanning fphases fof fthe
fnursing fprocess.
DIF: Cognitive fLevel: fKnowledge TOP: f Nursing fProcess: fAssessment
9. Which fof fthe ffollowing fis fan fexample fof fa fcorrectly fwritten fnursing fdiagnosis fstatement?
a. Altered ftissue fperfusion frelated fto fheart ffailure
b. Risk ffor fimpaired ftissue fintegrity frelated fto fsacral fredness
c. Ineffective fcoping frelated fto finsufficient fsense fof fcontrol.
d. Altered furinary felimination frelated fto furinary ftract finfection
ANS: f C
This fdiagnosis fstatement fincludes fa fNANDA fnursing fdiagnosis fand fan fetiology fthat
fdescribes fa fclient’s fresponse fto fa fhealth fproblem fthat fcan fbe ftreated fby f nursing. fThe
fuse fof f a f medical fdiagnosis f(as f in fthe fresponses f beginning f “Altered ftissue fperfusion”
fand f “Altered furinary felimination”) f is f not fappropriate. fThe fresponse f beginning f “Risk
f for fimpaired ftissue f integrity” fuses fthe fdefining fcharacteristics fas fthe fetiology.
DIF: Cognitive fLevel: fComprehension TOP: f Nursing fProcess: fDiagnosis
, 10. Which fof fthe ffollowing fincludes fthe fcomponents frequired ffor fa fcomplete fnursing
fdiagnosis fstatement?
a. A fproblem fand fthe fsuggested fclient fgoals for foutcomes
b. A fproblem, fits fcause, fand fobjective fdata fthat fsupport fthe fproblem
c. A fproblem fwith fall fits fpossible fcauses fand fthe fplanned finterventions
d. A fproblem fwith fits fetiology fand fthe fsigns fand fsymptoms fof fthe fproblem
ANS: f D
The fPES fformat fis fused fwhen fwriting fnursing fdiagnoses. fThe fsubjective, fas fwell fas
fobjective, fdata fshould f be f included f in fthe fdefining fcharacteristics. fInterventions fand
foutcomes fare f not fincluded f in fthe f nursing fdiagnosis fstatement.
DIF: Cognitive fLevel: fKnowledge TOP: f Nursing fProcess: fDiagnosis
11. Which fof fthe ffollowing frefers fto fa fsituation fthat fresults fin funintended fharm fto fthe
fclient fand fis frelated fto fthe fcare for fservices fprovided frather fthan fthe fclient’s f medical
fcondition?
a. Negligence
b. Adverse fevent
c. Incident freport
d. Nonmaleficence
ANS: f B
An fadverse fevent fis fan fevent fthat fresults fin funintended fharm fto fthe fclient fand fis
frelated fto fthe fcare for fservices fprovided fto fthe fclient frather fthan fto fthe fclient’s
funderlying fmedical fcondition.
DIF: Cognitive fLevel: fKnowledge TOP: f Nursing fProcess: fEvaluation
N fR fI fG fB.CfM
Ufthe
S fevidence-informed
N T O
12. When fusing fthe fFive fSteps fof fpractice f(EIP) fProcess, fwhich fof fthe
flowing felements fis fthe ffinal fstep fwhen fconstructing fa fclinical fquestion?
a. Comparison fof finterest
b. Population fof finterest
c. Outcome fof finterest
d. Timeframe fof finterest
ANS: f D
The forder fof fthe fnurse’s fstatements ffollows fthe fPICOT fformat fwith fthe ffinal fstep fbeing
fthe f“T”, for ftimeframe fof f interest.
DIF: Cognitive fLevel: fApplication TOP: f Nursing fProcess: fImplementation
Medical-Surgical Nursing in Canada
Sharon Lewis Margaret McLean Heitkemper Linda Bucher
4th Edition
TEST BANK
,Table of content
l Introduction to Medical-Surgical Nursing Practice in Canada
2 Cultural Competence and Health Equity in Nursing Care
3 Health History and Physical Examination
4 Patient and Caregiver Teaching
5 Chronic Illness
6 Community-Based Nursing and Home Care
7 Older Adults
8 Stress and Stress Management
9 Sleep and Sleep
Disorders I0 Pain
11 Substance Use
12 Complementary and Alternative Therapies
13 Palliative Care at the End of Life
14 Inflammation and Wound Healing
15 Genetics
16 Altered Immune Response and Transplantation
17 Infection and Human Immunodeficiency Virus Infection
18 Cancer
19 Fluid, Electrolyte, and Acid-Base Imbalances
20: Nursing Management: Preoperative Care
21: Nursing Management: Intraoperative Care
22: Nursing Management: Postoperative Care
23: Nursing Assessment: Visual and Auditory Systems
24: Nursing Management: Visual and Auditory Problems
25: Nursing Assessment: Integumentary System
26: Nursing Management: Integumentary Problems
27: Nursing Management: Burns
28: Nursing Assessment: Respiratory System
29: Nursing Management: Upper Respiratory Problems
30: Nursing Management: Lower Respiratory Problems
31: Nursing Management: Obstructive Pulmonary Diseases
32: Nursing Assessment: Hematological System
33: Nursing Management: Hematological Problems
34: Nursing Assessment: Cardiovascular System
35: Nursing Management: Hypertension
36: Nursing Management: Coronary Artery Disease and Acute Coronary
Syndrome
37: Nursing Management: Heart Failure
38: Nursing Management: Dysrhythmias
39: Nursing Management: Inflammatory and Structural Heart Disorders
40: Nursing Management: Vascular Disorders
41: Nursing Assessment: Gastro-intestinal System
42: Nursing Management: Nutritional Problems
43: Nursing Management: Obesity
44: Nursing Management: Upper Gastro-intestinal Problems
45: Nursing Management: Lower Gastro-intestinal Problems
46: Nursing Management: Liver, Pancreas, and Biliary Tract Problems
47: Nursing Management: Urinary System
,48: Nursing Management: Renal and Urological Problems
49: Nursing Management: Acute Kidney Injury and Chronic Kidney
Disease
50: Nursing Assessment: Endocrine System
51: Nursing Management: Endocrine Problems
52: Nursing Management: Diabetes Mellitus
53: Nursing Assessment: Reproductive System
54: Nursing Management: Breast Disorders
55: Nursing Management: Sexually Transmitted Infections
56: Nursing Management: Female Reproductive Problems
57: Nursing Management: Male Reproductive Problems
58: Nursing Assessment: Nervous System
59: Nursing Management: Acute Intracranial Problems
60: Nursing Management: Stroke
61: Nursing Management: Chronic Neurological Problems
62: Nursing Management: Delirium, Alzheimer's Disease, and Other
Dementias
63: Nursing Management: Peripheral Nerve and Spinal Cord Problems
64: Nursing Assessment: Musculo-skeletal System
65: Nursing Management: Musculo-skeletal Trauma and Orthopedic
Surgery
66: Nursing Management: Musculo-Skeletal Problems
67: Nursing Management: Arthritis and Connective Tissue Diseases
68: Nursing Management: Critical Care Environment
69: Nursing Management: Shock, Systemic Inflammatory Response
Syndrome, and Multiple-Organ Dysfunction Syndrome
70: Nursing Management: Respiratory Failure and Acute Respiratory
Distress Syndrome
71: Nursing Management: Emergency Care Situations
72: Emergency Management and Disaster Planning
,Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada
Lewis: Medical-Surgical Nursing in Canada, 4th 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,
conscientious, 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 nurse’s clinical experience is part of EIP, but clinical decision making also should
incorporate current research and research-based guidelines. Evidence from one clinical
research study does not provide an adequate substantiation for interventions. Evaluation of
client outcomes is important, but interventions should 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 eNxp lR
ainsIt heGnu B
r se.s’Cp r iMmar y use of the nursing process when
providing care to clients? U S N T 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 demonstrated
with this turning schedule?
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: D
, When fimplementing fcollaborative fnursing factions, fthe fnurse fis fresponsible fprimarily ffor
f monitoring f for fcomplications fof facute f illness for fproviding fcare fto fprevent for ftreat
fcomplications. fIndependent fnursing factions fare f focused fon f health fpromotion, f illness
fprevention, fand fclient fadvocacy. f A fdependent faction fwould frequire fa fphysician forder
fto fimplement. fCooperative fnursing ffunctions fare fnot fdescribed fas fone fof fthe fformal
fnursing f functions.
DIF: Cognitive fLevel: fApplication TOP: f Nursing fProcess: fImplementation
4. The fnurse fis fcaring ffor fa fclient fwho fhas fbeen fadmitted fto fthe fhospital ffor fsurgery fand
ftells fthe f nurse, f“I fdo fnot ffeel fright fabout fleaving f my fchildren fwith f my f neighbour.”
fWhich faction fshould fthe f nurse ftake fnext?
a. Reassure fthe fclient fthat fthese ffeelings fare fcommon ffor fparents.
b. Have fthe fclient fcall fthe fchildren fto fensure fthat fthey fare fdoing fwell.
c. Call fthe fneighbour fto fdetermine fwhether fadequate fchildcare fis fbeing fprovided.
d. Gather fmore fdata fabout fthe fclient’s ffeelings fabout fthe fchildcare farrangements.
ANS: f D
Since fa fcomplete fassessment fis fnecessary fin forder fto fidentify fa fproblem fand fchoose
fan fappropriate f intervention, fthe fnurse’s f first faction fshould f be fto fobtain f more
f information. fThe fother factions fmay fbe fappropriate, fbut fmore fassessment fis fneeded
fbefore fthe fbest fintervention fcan f be fchosen.
DIF: Cognitive fLevel: fApplication TOP: f Nursing fProcess: fAssessment
5. The fnurse fis fcaring ffor fa fclient fwho fhas fleft-sided fparalysis fas fthe fresult fof fa fstroke fand
assesses fa fpressure f injury fon the f c l i e nt ’ s l e ft h i p . fW hich fof fthe ffollowing fis fthe fmost
appropriate f nursing fdiagnosisNf fUoRr ft S hIi s f cN
Gl i e nB
Tt ?. C MO
a. Impaired fphysical fmobility frelated fto fdecrease fin fmuscle fcontrol f(left-
sided fparalysis)
b. Risk ffor fimpaired ftissue fintegrity fas fevidenced fby finsufficient fknowledge
fabout fprotecting ftissue f integrity
c. Impaired fskin fintegrity frelated fto fpressure fover fbony fprominence
f(impaired fcirculation)
d. Ineffective ftissue fperfusion frelated fto fsedentary flifestyle
ANS: f C
The fclient’s fmajor fproblem fis fthe fimpaired fskin fintegrity fas fdemonstrated fby fthe
fpresence fof fa fpressure f injury. fThe f nurse f is fable fto ftreat fthe fcause fof faltered
fcirculation fand fpressure f by f frequently frepositioning fthe fclient. fAlthough f left-sided
fweakness f is fa fproblem f for fthe fclient, fthe fnurse fcannot ftreat fthe fweakness. fThe f “risk
f for” fdiagnosis f is fnot fappropriate f for fthis fclient, fwho falready f has f impaired ftissue
f integrity. fThe fclient fdoes fhave f ineffective ftissue fperfusion, f but fthe f impaired fskin
f integrity fdiagnosis f indicates f more fclearly fwhat fthe fhealth fproblem f is.
DIF: Cognitive fLevel: fApplication TOP: f Nursing fProcess: fDiagnosis
6. The fnurse fcaring ffor fa fclient fwith fan finfection fhas fa fnursing fdiagnosis fof
fdeficient ffluid f volume frelated fto fexcessive fdiaphoresis. fWhich fof fthe ffollowing fis
fan fappropriate fclient foutcome?
a. Client fhas fa fbalanced fintake fand foutput.
b. Client’s fbedding fis fchanged fwhen fit fbecomes fdamp.
, c. Client funderstands fthe fneed ffor fincreased ffluid fintake.
d. Client’s fskin fremains fcool fand fdry fthroughout fhospitalization.
ANS: f A
This fstatement fgives fmeasurable fdata fshowing fresolution fof fthe fproblem fof fdeficient
f fluid fvolume fthat fwas fidentified fin fthe fnursing fdiagnosis fstatement. fThe fother
fstatements fwould fnot findicate fthat fthe fproblem fof fdeficient ffluid f volume fwas fresolved.
DIF: Cognitive fLevel: fApplication TOP: f Nursing fProcess: fPlanning
7. Which fof fthe ffollowing frepresents fa fnursing factivity fthat fis fcarried fout fduring fthe
fevaluation fphase fof fthe f nursing fprocess?
a. Determining fif finterventions fhave fbeen feffective fin fmeeting fclient foutcomes
b. Documenting fthe fnursing fcare fplan fin fthe fprogress fnotes fin fthe fmedical frecord
c. Deciding fwhether fthe fclient’s fhealth fproblems fhave fbeen fcompletely fresolved
d. Asking fthe fclient fto fevaluate fwhether fthe fnursing fcare fprovided fwas fsatisfactory
ANS: f A
Evaluation fconsists fof fdetermining fwhether fthe fdesired fclient foutcomes fhave fbeen fmet
fand fwhether fthe fnursing finterventions fwere fappropriate. fThe fother fresponses fdo fnot
fdescribe fthe fevaluation fphase.
DIF: Cognitive fLevel: fComprehension TOP: f Nursing fProcess: fEvaluation
8. Which fof fthe ffollowing fwould fthe fnurse fperform fduring fthe fassessment fphase fof fthe
fnursing fprocess?
a. Obtains fdata fwith fwhich fto fdiagnose fclient fproblems
b. Uses fclient fdata fto fdeveloNp fp Rior iIt y f nGursiBng.dCiagM
c. U rS
Teaches finterventions fto frelieve N T O noses
fclient fhealth fproblems
d. Assists fthe fclient fto fidentify frealistic foutcomes fto fhealth fproblems
ANS: f A
During fthe fassessment fphase, fthe fnurse fgathers finformation fabout fthe fclient. fThe fother
fresponses fare fexamples fof fthe fintervention, fdiagnosis, fand fplanning fphases fof fthe
fnursing fprocess.
DIF: Cognitive fLevel: fKnowledge TOP: f Nursing fProcess: fAssessment
9. Which fof fthe ffollowing fis fan fexample fof fa fcorrectly fwritten fnursing fdiagnosis fstatement?
a. Altered ftissue fperfusion frelated fto fheart ffailure
b. Risk ffor fimpaired ftissue fintegrity frelated fto fsacral fredness
c. Ineffective fcoping frelated fto finsufficient fsense fof fcontrol.
d. Altered furinary felimination frelated fto furinary ftract finfection
ANS: f C
This fdiagnosis fstatement fincludes fa fNANDA fnursing fdiagnosis fand fan fetiology fthat
fdescribes fa fclient’s fresponse fto fa fhealth fproblem fthat fcan fbe ftreated fby f nursing. fThe
fuse fof f a f medical fdiagnosis f(as f in fthe fresponses f beginning f “Altered ftissue fperfusion”
fand f “Altered furinary felimination”) f is f not fappropriate. fThe fresponse f beginning f “Risk
f for fimpaired ftissue f integrity” fuses fthe fdefining fcharacteristics fas fthe fetiology.
DIF: Cognitive fLevel: fComprehension TOP: f Nursing fProcess: fDiagnosis
, 10. Which fof fthe ffollowing fincludes fthe fcomponents frequired ffor fa fcomplete fnursing
fdiagnosis fstatement?
a. A fproblem fand fthe fsuggested fclient fgoals for foutcomes
b. A fproblem, fits fcause, fand fobjective fdata fthat fsupport fthe fproblem
c. A fproblem fwith fall fits fpossible fcauses fand fthe fplanned finterventions
d. A fproblem fwith fits fetiology fand fthe fsigns fand fsymptoms fof fthe fproblem
ANS: f D
The fPES fformat fis fused fwhen fwriting fnursing fdiagnoses. fThe fsubjective, fas fwell fas
fobjective, fdata fshould f be f included f in fthe fdefining fcharacteristics. fInterventions fand
foutcomes fare f not fincluded f in fthe f nursing fdiagnosis fstatement.
DIF: Cognitive fLevel: fKnowledge TOP: f Nursing fProcess: fDiagnosis
11. Which fof fthe ffollowing frefers fto fa fsituation fthat fresults fin funintended fharm fto fthe
fclient fand fis frelated fto fthe fcare for fservices fprovided frather fthan fthe fclient’s f medical
fcondition?
a. Negligence
b. Adverse fevent
c. Incident freport
d. Nonmaleficence
ANS: f B
An fadverse fevent fis fan fevent fthat fresults fin funintended fharm fto fthe fclient fand fis
frelated fto fthe fcare for fservices fprovided fto fthe fclient frather fthan fto fthe fclient’s
funderlying fmedical fcondition.
DIF: Cognitive fLevel: fKnowledge TOP: f Nursing fProcess: fEvaluation
N fR fI fG fB.CfM
Ufthe
S fevidence-informed
N T O
12. When fusing fthe fFive fSteps fof fpractice f(EIP) fProcess, fwhich fof fthe
flowing felements fis fthe ffinal fstep fwhen fconstructing fa fclinical fquestion?
a. Comparison fof finterest
b. Population fof finterest
c. Outcome fof finterest
d. Timeframe fof finterest
ANS: f D
The forder fof fthe fnurse’s fstatements ffollows fthe fPICOT fformat fwith fthe ffinal fstep fbeing
fthe f“T”, for ftimeframe fof f interest.
DIF: Cognitive fLevel: fApplication TOP: f Nursing fProcess: fImplementation
