TESTBANK
b
,Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada Lewis:
b b b b b b b b b
Medical-Surgical Nursing in Canada, 4th Canadian Edition
b b b b b b b
MULTIPLE CHOICE b
1. When caring for clients using evidence-informed practice, which of the following does the
b b b b b b b b b b b b
nurse use?
b b
a. Clinical judgement based on experience b b b b
b. Evidence from a clinical research study b b b b b
c. The best available evidence to guide clinical expertise
b b b b b b b
d. Evaluation of data showing that the client outcomes are met b b b b b b b b b
ANS: C b
Evidence-informed nursing practice is a continuous interactive process involving the explicit, b b b b b b b b b b
conscientious, and judicious consideration of the best available evidence to provide care. Four
b b b b b b b b b b b b b
primary elements are: (a) clinical state, setting, and circumstances; (b) client preferences and
b b b b b b b b b b b b b
actions; (c) best research evidence; and (d) health care resources. Clinical judgement based on the
b b b b b b b b b b b b b b b
nurse’s clinical experience is part of EIP, but clinical decision making also should incorporate
b b b b b b b b b b b b b b
current research and research-based guidelines. Evidence from one clinical research study does
b b b b b b b b b b b b
not provide an adequate substantiation for interventions. Evaluation of client outcomes is
b b b b b b b b b b b b
important, but interventions should be based on research from randomized control studies with a
b b b b b b b b b b b b b b
large number of subjects.
b b b b
DIF: Cognitive Level: Comprehension b b TOP: Nursing Process: Planning b b b
2. Which of the following best e x pl ai n s th e nu rse s ’ pri m ary use of the nursing process when
N R I G B.C M
b b b b b b b b b b b
providing care to clients?
b
USNT O b b b
b b b
a. To explain nursing interventions to other health care professionals
b b b b b b b b
b. As a problem-solving tool to identify and treat clients’ health care needs
b b b b b b b b b b b
c. As a scientific-based process of diagnosing the client’s health care problems
b b b b b b b b b b
d. To establish nursing theory that incorporates the biopsychosocial nature of humans
b b b b b b b b b b
ANS: B b
The nursing process is an assertive problem-solving approach to the identification and treatment
b b b b b b b b b b b b
of clients’ problems. Diagnosis is only one phase of the nursing process. The primary use of the
b b b b b b b b b b b b b b b b b
nursing process is in client care, not to establish nursing theory or explain nursing interventions to
b b b b b b b b b b b b b b b b
other health care professionals.
b b b b
DIF: Cognitive Level: Comprehension b b TOP: Nursing Process: Implementation b b b
3. The nurse is caring for a critically ill client in the intensive care unit and plans an every 2-hour
b b b b b b b b b b b b b b b b b b
turning schedule to prevent skin breakdown. Which type of nursing function is demonstrated with
b b b b b b b b b b b b b b
this turning schedule?
b b b
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: D b
, When implementing collaborative nursing actions, the nurse is responsible primarily for
b b b b b b b b b b
monitoring for complications of acute illness or providing care to prevent or treat complications.
b b b b b b b b b b b b b b
Independent nursing actions are focused on health promotion, illness prevention, and client
b b b b b b b b b b b b
advocacy. A dependent action would require a physician order to implement. Cooperative
b b b b b b b b b b b b
nursing functions are not described as one of the formal nursing functions.
b b b b b b b b b b b b
DIF: Cognitive Level: Application b b TOP: Nursing Process: Implementation b b b
4. The nurse is caring for a client who has been admitted to the hospital for surgery and tells the nurse,
b b b b b b b b b b b b b b b b b b b
“I do not feel right about leaving my children with my neighbour.” Which action should the
b b b b b b b b b b b b b b b b
nurse take next?
b b b
a. Reassure the client that these feelings are common for parents. b b b b b b b b b
b. Have the client call the children to ensure that they are doing well.
b b b b b b b b b b b b
c. Call the neighbour to determine whether adequate childcare is being provided.
b b b b b b b b b b
d. Gather more data about the client’s feelings about the childcare arrangements.
b b b b b b b b b b
ANS: D b
Since a complete assessment is necessary in order to identify a problem and choose an appropriate
b b b b b b b b b b b b b b b
intervention, the nurse’s first action should be to obtain more information. The other actions may
b b b b b b b b b b b b b b b
be appropriate, but more assessment is needed before the best intervention can be chosen.
b b b b b b b b b b b b b b
DIF: Cognitive Level: Application b b TOP: Nursing Process: Assessment b b b
5. The nurse is caring for a client who has left-sided paralysis as the result of a stroke and
b b b b b b b b b b b b b b b b b
assesses a pressure injury on the client’s left hip. Which of the following is the most
N
o rRtI
ShG
i sBcN
.C MTt? O
b b b b b b b b b b b b b b b b
appropriate nursing diagnosis fU
b lien b b b
b
b
b b b
b
b
a. Impaired physical mobility related to decrease in muscle control (left-sided b b b b b b b b b
paralysis)
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge about
b b b b b b b b b b
protecting tissue integrity
b b b
c. Impaired skin integrity related to pressure over bonyprominence (impaired b b b b b b b b b
circulation)
b
d. Ineffective tissue perfusion related to sedentary lifestyle b b b b b b
ANS: C b
The client’s major problem is the impaired skin integrity as demonstrated by the presence of a
b b b b b b b b b b b b b b b
pressure injury. The nurse is able to treat the cause of altered circulation and pressure by
b b b b b b b b b b b b b b b b
frequently repositioning the client. Although left-sided weakness is a problem for the client, the
b b b b b b b b b b b b b b
nurse cannot treat the weakness. The “risk for” diagnosis is not appropriate for this client, who
b b b b b b b b b b b b b b b b
already has impaired tissue integrity. The client does have ineffective tissue perfusion, but the
b b b b b b b b b b b b b b
impaired skin integrity diagnosis indicates more clearly what the health problem is.
b b b b b b b b b b b b
DIF: Cognitive Level: Application b b TOP: Nursing Process: Diagnosis b b b
6. The nurse caring for a client with an infection has a nursing diagnosis of deficient fluid
b b b b b b b b b b b b b b b
volume related to excessive diaphoresis. Which of the following is an appropriate client
b b b b b b b b b b b b b
outcome?
b
a. Client has a balanced intake and output. b b b b b b
b. Client’s bedding is changed when it becomes damp. b b b b b b b
, c. Client understands the need for increased fluid intake.
b b b b b b b
d. Client’s skin remains cool and dry throughout hospitalization. b b b b b b b
ANS: A b
This statement gives measurable data showing resolution of the problem of deficient fluid
b b b b b b b b b b b b
volume that was identified in the nursing diagnosis statement. The other statements would not
b b b b b b b b b b b b b b
indicate that the problem of deficient fluid volume was resolved.
b b b b b b b b b b
DIF: Cognitive Level: Application b b TOP: Nursing Process: Planning b b b
7. Which of the following represents a nursing activity that is carried out during the evaluation
b b b b b b b b b b b b b b
b phase of the nursing process?
b b b b
a. Determining if interventions have been effective in meeting client outcomes b b b b b b b b b
b. Documenting the nursing care plan in the progress notes in the medical record b b b b b b b b b b b b
c. Deciding whether the client’s health problems have been completely resolved
b b b b b b b b b
d. Asking the client to evaluate whether the nursing care provided was satisfactory
b b b b b b b b b b b
ANS: A b
Evaluation consists of determining whether the desired client outcomes have been met and whether
b b b b b b b b b b b b b
the nursing interventions were appropriate. The other responses do not describe the evaluation phase.
b b b b b b b b b b b b b b
DIF: Cognitive Level: Comprehension b b TOP: Nursing Process: Evaluation b b b
8. Which of the following would the nurse perform during the assessment phase of the nursing
b b b b b b b b b b b b b b
b process?
a. Obtains data with which to diagnose client problems b b b b b b b
b. Uses client data to develoNp pR
r ioriIt y nGursiBng.dCiagM
noses
USN T health problems
b b b b b b
c. Teaches interventions to relieve client b b b
b b
b
b
b b
d. Assists the client to identify realistic outcomes to health problems
b b b b b b b b b
ANS: A b
During the assessment phase, the nurse gathers information about the client. The other responses
b b b b b b b b b b b b b
are examples of the intervention, diagnosis, and planning phases of the nursing process.
b b b b b b b b b b b b b
DIF: Cognitive Level: Knowledge b b TOP: Nursing Process: Assessment b b b
9. Which of the following is an example of a correctly written nursing diagnosis statement?
b b b b b b b b b b b b b
a. Altered tissue perfusion related to heart failure b b b b b b
b. Risk for impaired tissue integrity related to sacral redness
b b b b b b b b
c. Ineffective coping related to insufficient sense of control. b b b b b b b
d. Altered urinary elimination related to urinary tract infection
b b b b b b b
ANS: C b
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes a
b b b b b b b b b b b b b
client’s response to a health problem that can be treated by nursing. The use of a medical
b b b b b b b b b b b b b b b b b
diagnosis (as in the responses beginning “Altered tissue perfusion” and “Altered urinary
b b b b b b b b b b b b
elimination”) is not appropriate. The response beginning “Risk for impaired tissue integrity”
b b b b b b b b b b b b
uses the defining characteristics as the etiology.
b b b b b b b
DIF: Cognitive Level: Comprehension b b TOP: Nursing Process: Diagnosis b b b
b
,Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada Lewis:
b b b b b b b b b
Medical-Surgical Nursing in Canada, 4th Canadian Edition
b b b b b b b
MULTIPLE CHOICE b
1. When caring for clients using evidence-informed practice, which of the following does the
b b b b b b b b b b b b
nurse use?
b b
a. Clinical judgement based on experience b b b b
b. Evidence from a clinical research study b b b b b
c. The best available evidence to guide clinical expertise
b b b b b b b
d. Evaluation of data showing that the client outcomes are met b b b b b b b b b
ANS: C b
Evidence-informed nursing practice is a continuous interactive process involving the explicit, b b b b b b b b b b
conscientious, and judicious consideration of the best available evidence to provide care. Four
b b b b b b b b b b b b b
primary elements are: (a) clinical state, setting, and circumstances; (b) client preferences and
b b b b b b b b b b b b b
actions; (c) best research evidence; and (d) health care resources. Clinical judgement based on the
b b b b b b b b b b b b b b b
nurse’s clinical experience is part of EIP, but clinical decision making also should incorporate
b b b b b b b b b b b b b b
current research and research-based guidelines. Evidence from one clinical research study does
b b b b b b b b b b b b
not provide an adequate substantiation for interventions. Evaluation of client outcomes is
b b b b b b b b b b b b
important, but interventions should be based on research from randomized control studies with a
b b b b b b b b b b b b b b
large number of subjects.
b b b b
DIF: Cognitive Level: Comprehension b b TOP: Nursing Process: Planning b b b
2. Which of the following best e x pl ai n s th e nu rse s ’ pri m ary use of the nursing process when
N R I G B.C M
b b b b b b b b b b b
providing care to clients?
b
USNT O b b b
b b b
a. To explain nursing interventions to other health care professionals
b b b b b b b b
b. As a problem-solving tool to identify and treat clients’ health care needs
b b b b b b b b b b b
c. As a scientific-based process of diagnosing the client’s health care problems
b b b b b b b b b b
d. To establish nursing theory that incorporates the biopsychosocial nature of humans
b b b b b b b b b b
ANS: B b
The nursing process is an assertive problem-solving approach to the identification and treatment
b b b b b b b b b b b b
of clients’ problems. Diagnosis is only one phase of the nursing process. The primary use of the
b b b b b b b b b b b b b b b b b
nursing process is in client care, not to establish nursing theory or explain nursing interventions to
b b b b b b b b b b b b b b b b
other health care professionals.
b b b b
DIF: Cognitive Level: Comprehension b b TOP: Nursing Process: Implementation b b b
3. The nurse is caring for a critically ill client in the intensive care unit and plans an every 2-hour
b b b b b b b b b b b b b b b b b b
turning schedule to prevent skin breakdown. Which type of nursing function is demonstrated with
b b b b b b b b b b b b b b
this turning schedule?
b b b
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: D b
, When implementing collaborative nursing actions, the nurse is responsible primarily for
b b b b b b b b b b
monitoring for complications of acute illness or providing care to prevent or treat complications.
b b b b b b b b b b b b b b
Independent nursing actions are focused on health promotion, illness prevention, and client
b b b b b b b b b b b b
advocacy. A dependent action would require a physician order to implement. Cooperative
b b b b b b b b b b b b
nursing functions are not described as one of the formal nursing functions.
b b b b b b b b b b b b
DIF: Cognitive Level: Application b b TOP: Nursing Process: Implementation b b b
4. The nurse is caring for a client who has been admitted to the hospital for surgery and tells the nurse,
b b b b b b b b b b b b b b b b b b b
“I do not feel right about leaving my children with my neighbour.” Which action should the
b b b b b b b b b b b b b b b b
nurse take next?
b b b
a. Reassure the client that these feelings are common for parents. b b b b b b b b b
b. Have the client call the children to ensure that they are doing well.
b b b b b b b b b b b b
c. Call the neighbour to determine whether adequate childcare is being provided.
b b b b b b b b b b
d. Gather more data about the client’s feelings about the childcare arrangements.
b b b b b b b b b b
ANS: D b
Since a complete assessment is necessary in order to identify a problem and choose an appropriate
b b b b b b b b b b b b b b b
intervention, the nurse’s first action should be to obtain more information. The other actions may
b b b b b b b b b b b b b b b
be appropriate, but more assessment is needed before the best intervention can be chosen.
b b b b b b b b b b b b b b
DIF: Cognitive Level: Application b b TOP: Nursing Process: Assessment b b b
5. The nurse is caring for a client who has left-sided paralysis as the result of a stroke and
b b b b b b b b b b b b b b b b b
assesses a pressure injury on the client’s left hip. Which of the following is the most
N
o rRtI
ShG
i sBcN
.C MTt? O
b b b b b b b b b b b b b b b b
appropriate nursing diagnosis fU
b lien b b b
b
b
b b b
b
b
a. Impaired physical mobility related to decrease in muscle control (left-sided b b b b b b b b b
paralysis)
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge about
b b b b b b b b b b
protecting tissue integrity
b b b
c. Impaired skin integrity related to pressure over bonyprominence (impaired b b b b b b b b b
circulation)
b
d. Ineffective tissue perfusion related to sedentary lifestyle b b b b b b
ANS: C b
The client’s major problem is the impaired skin integrity as demonstrated by the presence of a
b b b b b b b b b b b b b b b
pressure injury. The nurse is able to treat the cause of altered circulation and pressure by
b b b b b b b b b b b b b b b b
frequently repositioning the client. Although left-sided weakness is a problem for the client, the
b b b b b b b b b b b b b b
nurse cannot treat the weakness. The “risk for” diagnosis is not appropriate for this client, who
b b b b b b b b b b b b b b b b
already has impaired tissue integrity. The client does have ineffective tissue perfusion, but the
b b b b b b b b b b b b b b
impaired skin integrity diagnosis indicates more clearly what the health problem is.
b b b b b b b b b b b b
DIF: Cognitive Level: Application b b TOP: Nursing Process: Diagnosis b b b
6. The nurse caring for a client with an infection has a nursing diagnosis of deficient fluid
b b b b b b b b b b b b b b b
volume related to excessive diaphoresis. Which of the following is an appropriate client
b b b b b b b b b b b b b
outcome?
b
a. Client has a balanced intake and output. b b b b b b
b. Client’s bedding is changed when it becomes damp. b b b b b b b
, c. Client understands the need for increased fluid intake.
b b b b b b b
d. Client’s skin remains cool and dry throughout hospitalization. b b b b b b b
ANS: A b
This statement gives measurable data showing resolution of the problem of deficient fluid
b b b b b b b b b b b b
volume that was identified in the nursing diagnosis statement. The other statements would not
b b b b b b b b b b b b b b
indicate that the problem of deficient fluid volume was resolved.
b b b b b b b b b b
DIF: Cognitive Level: Application b b TOP: Nursing Process: Planning b b b
7. Which of the following represents a nursing activity that is carried out during the evaluation
b b b b b b b b b b b b b b
b phase of the nursing process?
b b b b
a. Determining if interventions have been effective in meeting client outcomes b b b b b b b b b
b. Documenting the nursing care plan in the progress notes in the medical record b b b b b b b b b b b b
c. Deciding whether the client’s health problems have been completely resolved
b b b b b b b b b
d. Asking the client to evaluate whether the nursing care provided was satisfactory
b b b b b b b b b b b
ANS: A b
Evaluation consists of determining whether the desired client outcomes have been met and whether
b b b b b b b b b b b b b
the nursing interventions were appropriate. The other responses do not describe the evaluation phase.
b b b b b b b b b b b b b b
DIF: Cognitive Level: Comprehension b b TOP: Nursing Process: Evaluation b b b
8. Which of the following would the nurse perform during the assessment phase of the nursing
b b b b b b b b b b b b b b
b process?
a. Obtains data with which to diagnose client problems b b b b b b b
b. Uses client data to develoNp pR
r ioriIt y nGursiBng.dCiagM
noses
USN T health problems
b b b b b b
c. Teaches interventions to relieve client b b b
b b
b
b
b b
d. Assists the client to identify realistic outcomes to health problems
b b b b b b b b b
ANS: A b
During the assessment phase, the nurse gathers information about the client. The other responses
b b b b b b b b b b b b b
are examples of the intervention, diagnosis, and planning phases of the nursing process.
b b b b b b b b b b b b b
DIF: Cognitive Level: Knowledge b b TOP: Nursing Process: Assessment b b b
9. Which of the following is an example of a correctly written nursing diagnosis statement?
b b b b b b b b b b b b b
a. Altered tissue perfusion related to heart failure b b b b b b
b. Risk for impaired tissue integrity related to sacral redness
b b b b b b b b
c. Ineffective coping related to insufficient sense of control. b b b b b b b
d. Altered urinary elimination related to urinary tract infection
b b b b b b b
ANS: C b
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes a
b b b b b b b b b b b b b
client’s response to a health problem that can be treated by nursing. The use of a medical
b b b b b b b b b b b b b b b b b
diagnosis (as in the responses beginning “Altered tissue perfusion” and “Altered urinary
b b b b b b b b b b b b
elimination”) is not appropriate. The response beginning “Risk for impaired tissue integrity”
b b b b b b b b b b b b
uses the defining characteristics as the etiology.
b b b b b b b
DIF: Cognitive Level: Comprehension b b TOP: Nursing Process: Diagnosis b b b
