TEST BANK for Lewis-s Medical-Surgical Nursing Assessment and Management of Clinical Problems 12th Edition By Harding & Kwong || Complete Solution Guide.

TEST BANK for Lewis's Medical-Surgical Nursing Assessment and
Management of Clinical Problems 12th Edition By Harding &
Kwong



Chapter01:Professional Nursing tl io




Harding: Lewis’s Medical-Surgical
t l t l t l Nursing, t l 12th t l Edition


MULTIPLECHOICE tl




1. The nurse completes an admission database and explains that the plan
tl tl of care and tl tl tl tl tl tl tl tl t l t l t l



discharge goals will be developed with the patient‗s input. The patient asks, ―How is
tl tl tl tl t l tl tl tl t l tl t l t l tl t l tl tl t l



this different from what the physician does?‖ Which response would the nurse provide?
t l tl tl tl tl tl tl tl tl tl tl tl tl



a. ―Theroleofthenurseistoadministermedicationsandothertreatmentsprescribed by tl tl tl tl tl tl tl



your physician.‖
tl tl



b. ―Inadditiontocaring for youwhile you aresick,the nurseswillhelp youplanto
tl tl tl io tl tl tl tl tl tl tl tl tl tl



maintain your health.‖
tl tl tl



c. ―Thenurse‗sjob isto collectinformationand communicate anyproblemsthat tl io tl io tl io io tl



occur to the physician.‖
tl tl tl tl



d. ―Nursesperformmanyofthe same procedures asthephysician,butnurses are
tl tl tl tl tl tl tl tl tl



with the patients for a longer time than the physician.‖
tl tl tl tl tl tl tl tl tl tl




ANS: B t l



The American Nurses Association (ANA) definition of nursing describes the role of nurses
tl tl tl tl tl tl tl tl tl tl tl tl



inpromoting health. The other responses describe dependent and collaborative functions of
tl tl tl tl tl tl tl tl tl tl tl



the nursing role but do not accurately describe the nurse‗s unique role in the health care
tl tl tl tl tl tl tl tl tl tl tl tl tl tl tl tl



system.
tl




DIF: tl tl tl tl t l CognitiveLevel:Analyze(Analysis) tl tl



TOP: tl tl tl tl t l Nursing Process: Implementation MSC: NCLEX:SafeandEffectiveCareEnvironment
io tl tl tl tl tl tl tl tl tl tl tl t l tl tl tl tl tl




2. Whichstatement bythe nurse accuratelydescribes the useof evidence-based practice (EBP)?
tl tl tl tl t l tl tl tl tl tl



a. ―Patientcareisbasedonclinicaljudgment,experience, andtraditions.‖
tl tl tl tl tl tl tl tl tl



b. ―Dataareanalyzedlatertoshowthatthepatientoutcomesareconsistentlymet.‖
tl tl tl tl tl tl tl



c. ―Researchfrom allpublishedarticles areused as aguideforplanningpatientcare.‖ tl tl tl tl tl tl tl tl tl tl tl



d. ―Recommendationsarebased on research,clinical expertise,and patient tl tl tl tl io



tl preferences.‖
ANS: D t l



Evidence-based practice (EBP) is the use of the best research-based evidence combined tl tl tl tl tl tl tl tl tl tl tl



withclinician expertise and consideration of patient preferences. Clinical judgment based
tl tl tl tl tl tl tl tl tl tl



onthe nurse‗s clinical experience is part of EBP, but clinical decision making should also
tl tl tl tl tl tl tl tl tl tl tl tl tl tl tl



incorporate current research and research-based guidelines. Evaluation of patient outcomes
tl tl tl tl tl tl tl tl tl tl



isimportant, but data analysis is not required to use EBP. All published articles do not
tl tl tl tl tl tl tl tl tl tl tl tl tl tl tl



provide research evidence; interventions should be based on credible research, preferably
tl tl tl tl tl tl tl tl tl tl tl



randomizedcontrolled studies with a large numberof subjects.
tl tl tl tl tl tl tl tl




DIF: Cognitive Level: Understand (Comprehension) TOP: tl tl tl



NursingProcess:PlanningMSC: NCLEX: Safe and Effective Care Environment
tl tl io tl tl t l tl tl tl tl tl




3. Which statement bythe nurseprovides a clear explanation ofthe nursingprocess?
tl tl tl tl tl tl tl tl tl tl tl



a. ―Thenursingprocessisaresearchmethodofdiagnosing thepatient‗shealthcare tl tl tl tl tl io tl tl tl



tl problems.‖
?

,b. ―Thenursing processis usedprimarilytoexplain nursing interventionstoother
io tl tl tl io io tl tl



health care professionals.‖
tl tl tl



c. ―Thenursing processisa problem-solving toolused toidentifyandmanage the
io tl tl tl io tl tl tl tl




?

, patients‗healthcareneeds.‖ tl tl tl



d. ―Thenursing processis basedonnursingtheorythat incorporates the io tl io tl tl



tl biopsychosocial nature of humans.‖ tl tl tl




ANS: C t l



The nursing process is a problem-solving approach to the identification and treatment of
tl tl tl tl tl tl tl tl tl tl tl tl



patients‗ problems. Nursing process does not require research methods for diagnosis.
tl tl tl tl tl tl tl tl tl tl tl



Theprimaryuse of the nursing process is in patient care, not to establish nursing theoryor
tl tl tl tl tl tl tl tl tl tl tl tl tl tl tl



explainnursinginterventions to other health care professionals.
tl io tl tl tl tl tl tl




DIF: Cognitive Level: Understand (Comprehension) TOP: tl tl tl



NursingProcess:EvaluationMSC: NCLEX: Safe and Effective Care Environment
t l tl tl io tl tl t l tl tl tl tl tl




4. A patient admitted to the hospital for surgery tells the nurse, ―I do not feel
tl tl tl tl tl tl tl tl tl tl tl tl tl tl



comfortableleaving my children with my parents.‖ Which action would the nursetake
tl tl tl tl tl tl tl tl tl tl tl tl



next?
tl



a. Reassurethepatient that thesefeelings arecommon forparents. tl tl tl tl tl tl tl tl



b. Havethe patient call the children to ensure that theyaredoingwell.
tl tl tl tl tl tl tl tl tl tl tl



c. Gatherinformation onthepatient‗sconcerns about thechildcarearrangements. tl tl tl tl tl tl tl



d. Callthepatient‗sparents tl tl tl



todeterminewhetheradequatechildcareisbeingprovided.
tl tl tl tl tl tl tl io




ANS: C t l



Because a complete assessment is necessary in order to identify a problem and choose an
tl tl tl tl tl tl tl tl tl tl tl tl tl tl



appropriate intervention, the nurse‗s first action should be to obtain more information.
tl tl tl tl tl tl tl tl tl tl tl tl



Theother actions maybe appropriate, but more assessment is needed before the best
tl tl tl tl tl tl tl tl tl tl tl tl tl



interventioncan be chosen.
tl io tl tl




DIF: CognitiveLevel:Analyze(Analysis) tl tl tl



TOP: NursingProcess: Assessment tl tl MSC: NCLEX:PsychosocialIntegrity t l tl tl




5. Apatient withabacterial infectionishypovolemic duetoafever and
tl tl tl tl tl tl tl tl tl tl tl tl



excessivediaphoresis.Which expected outcome would the nurse select for this
tl tl tl tl tl tl tl tl tl tl



patient?
tl



a. Patienthasabalanced intakeand output. tl tl tl tl tl



b. Patient‗sbeddingiskeptclean andfreeofmoisture. tl tl tl tl tl tl



c. Patient understands theneedforincreased fluidintake. tl tl tl tl tl tl



d. Patient‗s skin remains cool and dry throughout hospitalization. tl t l t l t l t l tl t l




ANS: A t l



Balanced intake and output gives measurable data showingresolution of the problem
tl tl tl tl tl tl tl tl tl tl



ofdeficient fluid volume. The other statements would not indicate that the problem
tl tl tl tl tl tl tl tl tl tl tl tl



ofhypovolemia was resolved.
tl tl tl tl




DIF: Cognitive Level: Apply(Application) tl tl tl TOP: Nursing Process: tl tltl io



PlanningMSC: NCLEX: Physiological Integrity
tl io tl tl t l tl tl




6. Whichstatement describes the purposeoftheevaluation phase ofthe nursingprocess?
tl tl tl tl tl tl tl tl tl tl tl tl



a. Todocument the nursing careplan in theprogress notes ofthehealth record
tl tl tl tl tl tl tl tl tl tl tl tl tl



b. Todetermineifinterventions havebeen effective in meetingpatient outcomes
tl tl tl tl tl tl tl tl tl



c. Todecidewhetherthepatient‗s healthproblems havebeen completelyresolved
tl tl tl tl tl tl tl tl tl



d. Toestablish if thepatient agrees thatthenursingcareprovided was satisfactory
tl tl tl tl tl tl tl tl tl tl tl tl




ANS: B t l




?

, Evaluation consists of determining whether the desired patient outcomes have t l t l t l t l t l t l t l t l t l



been metand whether the nursing interventions were appropriate. The other responses do
t l t l tl tl tl tl tl tl tl tl tl tl tl



not describe theevaluation phase.
t l tl tl tl




DIF: Cognitive Level: Understand (Comprehension)
tl tl tl tl t l TOP: tl tl tl Nursing
Process:EvaluationMSC: NCLEX: Safe and Effective Care Environment
tl tl tl tl tl tl tl tl




7. Whichstatement describes the purposeoftheassessment phaseofthenursingprocess?
tl tl tl tl tl tl tl tl tl tl tl tl



a. Toteachinterventionsthatrelievehealthproblems
tl tl tl tl tl tl



b. To usepatient datato evaluatepatient careoutcomes
tl tl tl tl tl tl tl tl



c. Toobtaindatatodiagnosepatient strengths and problems
tl tl tl tl tl tl tl tl



d. Tohelp thepatient identifyrealisticoutcomes for healthproblems
tl tl tl tl tl tl tl tl




ANS: C t l



During theassessment phase,the nurse gathersinformation about thepatient to diagnosepatient
io tl tl tl tl tl tl tl tl tl tl tl



strengths and problems. The other responses are examples of the planning,intervention, and
tl tl tl tl tl tl tl tl tl tl tl tl tl



evaluation phases of the nursing process.
tl tl tl tl tl tl




DIF: CognitiveLevel:Understand(Comprehension) tl tl tl



TOP: NursingProcess: Assessment MSC: NCLEX:SafeandEffectiveCareEnvironment tl tl t l tl tl tl tl tl




8. Whendevelopingthe plan ofcare, which components would thenurseincludein
tl tl tl tl tl tl tl tl tl tl tl tl



theclinicalproblem statement?
tl tl tl



a. Theproblem and thesuggested patient goals oroutcomes tl tl tl tl tl tl tl



b. Theproblem,its causes, andthesigns and symptoms oftheproblem
tl tl tl tl tl tl tl tl tl tl tl



c. Theproblem with thepossible etiologyand theplanned interventions
tl tl tl tl tl tl tl tl



d. Theproblem, itspathophysiology, and theexpected outcome tl tl tl tl tl tl




ANS: B t l



When writing clinical problems or nursing diagnoses, the subjective as well as objective data
tl tl tl tl tl tl tl tl tl tl tl tl tl



to support the problem‗s existence should be included. Goals, outcomes, and interventions
tl tl tl tl tl tl tl tl tl tl tl tl



arenot included in the problem statement.
tl tl tl tl tl tl




DIF: Cognitive Level: Understand(Comprehension) TOP: Nursing Process: tl tl tl tl t l io



DiagnosisMSC: NCLEX: Safe and Effective Care Environment
tl io tl tl t l tl tl tl tl tl




9. Whichpatient caretask would the nursedelegate to experienced assistive personnel(AP)?
tl tl tl tl tl tl tl tl tl tl tl tl



a. Instruct thepatient about the need to alternate activityand rest. tl tl tl tl tl tl tl tl tl



b. Monitorlevel ofshortness ofbreath orfatigue afterambulation. tl tl tl tl tl tl tl tl tl



c. Obtainthepatient‗sbloodpressureandpulserate afterambulation. tl tl tl tl tl tl tl



d. Determinewhetherthe patient is readyto increase theactivitylevel. tl tl tl tl tl tl tl tl




ANS: C t l



AP education includes accurate vital sign measurement. Assessment and patient
tl tl tl tl tl tl tl tl tl



teachingrequire registered nurse education and scopeof practice and cannot be delegated.
tl tl tl tl tl tl tl tl tl tl tl tl




DIF: Cognitive Level: Apply(Application) TOP: Nursing Process: tl tl tl tl tltl io



PlanningMSC: NCLEX: Safe and Effective Care Environment
tl io tl tl t l tl tl tl tl tl




?