Test Bank for Lewis's Medical-Surgical Nursing in Canada, 5th Edition(Tyerman, 2023), | All Chapters With Rationales

Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada
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,f Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
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MULTIPLE CHOICE f




1. When caring for clients using evidence-informed practice, which of the following does the
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nurse use?
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a. Clinical judgement based on experience f f f f


b. Evidence from a clinical research study f f f f f


c. The best available evidence to guide clinical expertise
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d. Evaluation of data showing that the client outcomes are met f f f f f f f f f




ANS: C f


Evidence-informed nursing practice is a continuous interactive process involving the explicit, f f f f f f f f f f


conscientious, and judicious consideration of the best available evidence to provide care. Four
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primary elements are: (a) clinical state, setting, and circumstances; (b) client preferences and
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actions; (c) best research evidence; and (d) health care resources. Clinical judgement based on
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the nurse’s clinical experience is part of EIP, but clinical decision making also should
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incorporate current research and research-based guidelines. Evidence from one clinical
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research study does not provide an adequate substantiation for interventions. Evaluation of
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client outcomes is important, but interventions should be based on research from randomized
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control studies with a large number of subjects.
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DIF: Cognitive Level: Comprehension f f TOP: Nursing Process: Planning f f f




2. Which of the following best e x p l a i n s t h e n u r s e s ’ primary use of the nursing process when
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N R I G B.C M
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providing care to clients? USNT O f f f f f f


a. To explain nursing interventions to other health care professionals
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b. As a problem-solving tool to identify and treat clients’ health care needs
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c. As a scientific-based process of diagnosing the client’s health care problems
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d. To establish nursing theory that incorporates the biopsychosocial nature of humans
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ANS: B f


The nursing process is an assertive problem-solving approach to the identification and
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treatment of clients’ problems. Diagnosis is only one phase of the nursing process. The primary
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use of the nursing process is in client care, not to establish nursing theory or explain nursing
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interventions to other health care professionals.
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DIF: Cognitive Level: Comprehension f f TOP: Nursing Process: Implementation
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3. The nurse is caring for a critically ill client in the intensive care unit and plans an every 2-hour
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turning schedule to prevent skin breakdown. Which type of nursing function is demonstrated
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with this turning schedule?
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a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: D f




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, When implementing collaborative nursing actions, the nurse is responsible primarily for
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monitoring for complications of acute illness or providing care to prevent or treat
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complications. Independent nursing actions are focused on health promotion, illness
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prevention, and client advocacy. A dependent action would require a physician order to
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implement. Cooperative nursing functions are not described as one of the formal nursing
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functions.
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DIF: Cognitive Level: Application f f TOP: Nursing Process: Implementation f f f




4. The nurse is caring for a client who has been admitted to the hospital for surgery and tells the
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nurse, “I do not feel right about leaving my children with my neighbour.” Which action should
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the nurse take next?
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a. Reassure the client that these feelings are common for parents. f f f f f f f f f


b. Have the client call the children to ensure that they are doing well.
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c. Call the neighbour to determine whether adequate childcare is being provided.
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d. Gather more data about the client’s feelings about the childcare arrangements.
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ANS: D f


Since a complete assessment is necessary in order to identify a problem and choose an
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appropriate intervention, the nurse’s first action should be to obtain more information. The
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other actions may be appropriate, but more assessment is needed before the best intervention
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can be chosen.
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DIF: Cognitive Level: Application f f TOP: Nursing Process: Assessment f f f




5. The nurse is caring for a client who has left-sided paralysis as the result of a stroke and
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assesses a pressure injury on the clie nt’s left h ip . W hich of the following is the most
N fUoRr tShIi s cNGl i e nTBt ?. CO M
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appropriate nursing diagnosis f f f f f


a. Impaired physical mobility related to decrease in muscle control (left-sided f f f f f f f f f


paralysis)
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b. Risk for impaired tissue integrity as evidenced by insufficient knowledge about
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protecting tissue integrity
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c. Impaired skin integrity related to pressure over bony prominence (impaired f f f f f f f f f


circulation)
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d. Ineffective tissue perfusion related to sedentary lifestyle f f f f f f




ANS: C f


The client’s major problem is the impaired skin integrity as demonstrated by the presence of a
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pressure injury. The nurse is able to treat the cause of altered circulation and pressure by
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frequently repositioning the client. Although left-sided weakness is a problem for the client,
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the nurse cannot treat the weakness. The “risk for” diagnosis is not appropriate for this client,
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who already has impaired tissue integrity. The client does have ineffective tissue perfusion, but
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the impaired skin integrity diagnosis indicates more clearly what the health problem is.
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DIF: Cognitive Level: Application f f TOP: Nursing Process: Diagnosis f f f




6. The nurse caring for a client with an infection has a nursing diagnosis of deficient fluid
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volume related to excessive diaphoresis. Which of the following is an appropriate client
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outcome?
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a. Client has a balanced intake and output. f f f f f f


b. Client’s bedding is changed when it becomes damp. f f f f f f f




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, c. Client understands the need for increased fluid intake.
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d. Client’s skin remains cool and dry throughout hospitalization.
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ANS: A f


This statement gives measurable data showing resolution of the problem of deficient fluid
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volume that was identified in the nursing diagnosis statement. The other statements would not
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indicate that the problem of deficient fluid volume was resolved.
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DIF: Cognitive Level: Application f f TOP: Nursing Process: Planning f f f




7. Which of the following represents a nursing activity that is carried out during the evaluation
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phase of the nursing process?
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a. Determining if interventions have been effective in meeting client outcomes f f f f f f f f f


b. Documenting the nursing care plan in the progress notes in the medical record f f f f f f f f f f f f


c. Deciding whether the client’s health problems have been completely resolved
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d. Asking the client to evaluate whether the nursing care provided was satisfactory
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ANS: A f


Evaluation consists of determining whether the desired client outcomes have been met and
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whether the nursing interventions were appropriate. The other responses do not describe the
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evaluation phase.
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DIF: Cognitive Level: Comprehension f f TOP: Nursing Process: Evaluation f f f




8. Which of the following would the nurse perform during the assessment phase of the nursing
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process?
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a. Obtains data with which to diagnose client problems f f f f f f f


b. Uses client data to develoNp pR
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riori in.
gC OMnoses
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c. Teaches interventions to relieve client health problems f
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d. Assists the client to identify realistic outcomes to health problems
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ANS: A f


During the assessment phase, the nurse gathers information about the client. The other
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responses are examples of the intervention, diagnosis, and planning phases of the nursing
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process.
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DIF: Cognitive Level: Knowledge f f TOP: Nursing Process: Assessment f f f




9. Which of the following is an example of a correctly written nursing diagnosis statement?
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a. Altered tissue perfusion related to heart failure
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b. Risk for impaired tissue integrity related to sacral redness
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c. Ineffective coping related to insufficient sense of control. f f f f f f f


d. Altered urinary elimination related to urinary tract infection
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ANS: C f


This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes a
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client’s response to a health problem that can be treated by nursing. The use of a medical
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diagnosis (as in the responses beginning “Altered tissue perfusion” and “Altered urinary
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elimination”) is not appropriate. The response beginning “Risk for impaired tissue integrity”
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uses the defining characteristics as the etiology.
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DIF: Cognitive Level: Comprehension f f TOP: Nursing Process: Diagnosis f f f




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