Medical-Surgical Nursing
8th Edition
• Author(s)Adrianne Dill Linton;
Mary Ann Matteson
• Print ISBN: 9780323826716
TEST BANK
Question 1 (MCQ)
Clinical Scenario
,A newly licensed nurse is caring for four patients on a medical-
surgical unit. During morning rounds, the nurse notices that one
patient who was stable overnight is now confused and restless.
Question Stem
Which nursing action best demonstrates clinical judgment?
Answer Options
A. Document the change at the end of the shift
B. Notify the provider immediately without further assessment
C. Assess vital signs, oxygenation, and neurological status
before determining next steps
D. Ask the nursing assistant whether the patient seemed
confused earlier
Correct Answer
C. Assess vital signs, oxygenation, and neurological status
before determining next steps
Detailed Rationale
Clinical judgment begins with recognizing cues and gathering
additional assessment data before making conclusions. A
sudden change in mental status may indicate hypoxia, infection,
stroke, medication effects, or metabolic disturbances.
Performing a focused assessment helps the nurse identify the
cause and prioritize interventions.
,Incorrect Option Analysis
A. Document the change at the end of the shift
• Incorrect because assessment and intervention are
delayed.
• Misconception: Documentation alone is sufficient.
• Safety Risk: Deterioration may go unrecognized.
B. Notify the provider immediately without further
assessment
• Incorrect because insufficient data are available.
• Misconception: Reporting should occur before assessment.
• Safety Risk: Incomplete communication.
D. Ask the nursing assistant
• Incorrect because delegated observations do not replace
nursing assessment.
• Safety Risk: Critical findings may be missed.
Nursing Process Linkage
Assessment
NCJMM Competencies
• Recognize Cues
• Analyze Cues
, • Take Action
Difficulty
Moderate
Bloom's Level
Analyze
NCLEX Client Needs
Management of Care
Learning Objective
Apply clinical judgment principles when a patient's condition
changes.
Question 2 (SATA)
Clinical Scenario
A nurse is reviewing professional responsibilities associated
with medical-surgical nursing practice.
Question Stem
Which responsibilities are consistent with the role of the
professional medical-surgical nurse? Select all that apply.
Answer Options
A. Advocate for patient preferences
8th Edition
• Author(s)Adrianne Dill Linton;
Mary Ann Matteson
• Print ISBN: 9780323826716
TEST BANK
Question 1 (MCQ)
Clinical Scenario
,A newly licensed nurse is caring for four patients on a medical-
surgical unit. During morning rounds, the nurse notices that one
patient who was stable overnight is now confused and restless.
Question Stem
Which nursing action best demonstrates clinical judgment?
Answer Options
A. Document the change at the end of the shift
B. Notify the provider immediately without further assessment
C. Assess vital signs, oxygenation, and neurological status
before determining next steps
D. Ask the nursing assistant whether the patient seemed
confused earlier
Correct Answer
C. Assess vital signs, oxygenation, and neurological status
before determining next steps
Detailed Rationale
Clinical judgment begins with recognizing cues and gathering
additional assessment data before making conclusions. A
sudden change in mental status may indicate hypoxia, infection,
stroke, medication effects, or metabolic disturbances.
Performing a focused assessment helps the nurse identify the
cause and prioritize interventions.
,Incorrect Option Analysis
A. Document the change at the end of the shift
• Incorrect because assessment and intervention are
delayed.
• Misconception: Documentation alone is sufficient.
• Safety Risk: Deterioration may go unrecognized.
B. Notify the provider immediately without further
assessment
• Incorrect because insufficient data are available.
• Misconception: Reporting should occur before assessment.
• Safety Risk: Incomplete communication.
D. Ask the nursing assistant
• Incorrect because delegated observations do not replace
nursing assessment.
• Safety Risk: Critical findings may be missed.
Nursing Process Linkage
Assessment
NCJMM Competencies
• Recognize Cues
• Analyze Cues
, • Take Action
Difficulty
Moderate
Bloom's Level
Analyze
NCLEX Client Needs
Management of Care
Learning Objective
Apply clinical judgment principles when a patient's condition
changes.
Question 2 (SATA)
Clinical Scenario
A nurse is reviewing professional responsibilities associated
with medical-surgical nursing practice.
Question Stem
Which responsibilities are consistent with the role of the
professional medical-surgical nurse? Select all that apply.
Answer Options
A. Advocate for patient preferences
