TEST BANK
,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 e x p l ai ns th e nu rse s ’ pri m ar y use of the nursing process when
N R I G B.C M
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 implementing collaborative nursing actions, the nurse is responsible primarily for
monitoring for complications of acute illness or providing care to prevent or treat
complications. Independent nursing actions are focused on health promotion, illness
prevention, and client advocacy. A dependent action would require a physician order to
implement. Cooperative nursing functions are not described as one of the formal nursing
functions.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
4. The nurse is caring for a client who has been admitted to the hospital for surgery and tells the
nurse, “I do not feel right about leaving my children with my neighbour.” Which action
should the nurse take next?
a. Reassure the client that these feelings are common for parents.
b. Have the client call the children to ensure that they are doing well.
c. Call the neighbour to determine whether adequate childcare is being provided.
d. Gather more data about the client’s feelings about the childcare arrangements.
ANS: D
Since a complete assessment is necessary in order to identify a problem and choose an
appropriate intervention, the nurse’s first action should be to obtain more information. The
other actions may be appropriate, but more assessment is needed before the best intervention
can be chosen.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
5. The nurse is caring for a client who has left-sided paralysis as the result of a stroke and
assesses a pressure injury on the client’s left hip. Which of the following is the most
appropriate nursing diagnosis fN
Uo rRt Sh I
i s cG B.C
NlienTt? OM
a. Impaired physical mobility related to decrease in muscle control (left-sided
paralysis)
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge about
protecting tissue integrity
c. Impaired skin integrity related to pressure over bony prominence (impaired
circulation)
d. Ineffective tissue perfusion related to sedentary lifestyle
ANS: C
Thexclient’sxmajorxproblemxisxtheximpairedxskinxintegrityxasxdemonstratedxbyxthexpresencexo
fxaxpressurexinjury.xThexnursexisxablextoxtreatxthexcausexofxalteredxcirculationxandxpressurex
byxfrequentlyxrepositioningxthexclient.xAlthoughxleft-
sidedxweaknessxisxaxproblemxforxthexclient,xthexnursexcannotxtreatxthexweakness.xThex“riskx
for”xdiagnosisxisxnotxappropriatexforxthisxclient,xwhoxalreadyxhasximpairedxtissuexintegrity.x
Thexclientxdoesxhavexineffectivextissuexperfusion,xbutxtheximpairedxskinxintegrityxdiagnosisx
indicatesxmorexclearlyxwhatxthexhealthxproblemxis.
DIF: CognitivexLevel:xApplication TOP:x NursingxProcess:xDiagnosis
6. Thexnursexcaringxforxaxclientxwithxanxinfectionxhasxaxnursingxdiagnosisxofxdeficientxfl
uidxvolumexrelatedxtoxexcessivexdiaphoresis.xWhichxofxthexfollowingxisxanxappropriate
xclientxoutcome?
a. Clientxhasxaxbalancedxintakexandxoutput.
b. Client’sxbeddingxisxchangedxwhenxitxbecomesxdamp.
, c. Clientxunderstandsxthexneedxforxincreasedxfluidxintake.
d. Client’sxskinxremainsxcoolxandxdryxthroughoutxhospitalization.
ANS:x A
Thisxstatementxgivesxmeasurablexdataxshowingxresolutionxofxthexproblemxofxdeficientxfluidx
volumexthatxwasxidentifiedxinxthexnursingxdiagnosisxstatement.xThexotherxstatementsxwouldx
notxindicatexthatxthexproblemxofxdeficientxfluidxvolumexwasxresolved.
DIF: CognitivexLevel:xApplication TOP:x NursingxProcess:xPlanning
7. Whichxofxthexfollowingxrepresentsxaxnursingxactivityxthatxisxcarriedxoutxduringxthexevaluati
onxphasexofxthexnursingxprocess?
a. Determiningxifxinterventionsxhavexbeenxeffectivexinxmeetingxclientxoutcomes
b. Documentingxthexnursingxcarexplanxinxthexprogressxnotesxinxthexmedicalxrecord
c. Decidingxwhetherxthexclient’sxhealthxproblemsxhavexbeenxcompletelyxresolved
d. Askingxthexclientxtoxevaluatexwhetherxthexnursingxcarexprovidedxwasxsatisfactory
ANS:x A
Evaluationxconsistsxofxdeterminingxwhetherxthexdesiredxclientxoutcomesxhavexbeenxmetxandxwhe
therxthexnursingxinterventionsxwerexappropriate.xThexotherxresponsesxdoxnotxdescribexthexevaluati
onxphase.
DIF: CognitivexLevel:xComprehension TOP:x NursingxProcess:xEvaluation
8. Whichxofxthexfollowingxwouldxthexnursexperformxduringxthexassessmentxphasexofxthexnursi
ngxprocess?
a. Obtainsxdataxwithxwhichxtoxdiagnosexclientxproblems
b. UsesxclientxdataxtoxdeveloN
p xp R
U SxIclient
r iori t y xnGursiBng.dCiagM
noses
c. Teachesxinterventionsxtoxrelieve N Txhealthxproblems
d. Assistsxthexclientxtoxidentifyxrealisticxoutcomesxtoxhealthxproblems
ANS:x A
Duringxthexassessmentxphase,xthexnursexgathersxinformationxaboutxthexclient.xThexotherxres
ponsesxarexexamplesxofxthexintervention,xdiagnosis,xandxplanningxphasesxofxthexnursingxproc
ess.
DIF: CognitivexLevel:xKnowledge TOP:x NursingxProcess:xAssessment
9. Whichxofxthexfollowingxisxanxexamplexofxaxcorrectlyxwrittenxnursingxdiagnosisxstatement?
a. Alteredxtissuexperfusionxrelatedxtoxheartxfailure
b. Riskxforximpairedxtissuexintegrityxrelatedxtoxsacralxredness
c. Ineffectivexcopingxrelatedxtoxinsufficientxsensexofxcontrol.
d. Alteredxurinaryxeliminationxrelatedxtoxurinaryxtractxinfection
ANS:x C
ThisxdiagnosisxstatementxincludesxaxNANDAxnursingxdiagnosisxandxanxetiologyxthatxdescrib
esxaxclient’sxresponsextoxaxhealthxproblemxthatxcanxbextreatedxbyxnursing.xThexusexofxaxmed
icalxdiagnosisx(asxinxthexresponsesxbeginningx“Alteredxtissuexperfusion”xandx“Alteredxurina
ryxelimination”)xisxnotxappropriate.xThexresponsexbeginningx“Riskxforximpairedxtissuexinteg
rity”xusesxthexdefiningxcharacteristicsxasxthexetiology.
DIF: CognitivexLevel:xComprehension TOP:x NursingxProcess:xDiagnosis
,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 e x p l ai ns th e nu rse s ’ pri m ar y use of the nursing process when
N R I G B.C M
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 implementing collaborative nursing actions, the nurse is responsible primarily for
monitoring for complications of acute illness or providing care to prevent or treat
complications. Independent nursing actions are focused on health promotion, illness
prevention, and client advocacy. A dependent action would require a physician order to
implement. Cooperative nursing functions are not described as one of the formal nursing
functions.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
4. The nurse is caring for a client who has been admitted to the hospital for surgery and tells the
nurse, “I do not feel right about leaving my children with my neighbour.” Which action
should the nurse take next?
a. Reassure the client that these feelings are common for parents.
b. Have the client call the children to ensure that they are doing well.
c. Call the neighbour to determine whether adequate childcare is being provided.
d. Gather more data about the client’s feelings about the childcare arrangements.
ANS: D
Since a complete assessment is necessary in order to identify a problem and choose an
appropriate intervention, the nurse’s first action should be to obtain more information. The
other actions may be appropriate, but more assessment is needed before the best intervention
can be chosen.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
5. The nurse is caring for a client who has left-sided paralysis as the result of a stroke and
assesses a pressure injury on the client’s left hip. Which of the following is the most
appropriate nursing diagnosis fN
Uo rRt Sh I
i s cG B.C
NlienTt? OM
a. Impaired physical mobility related to decrease in muscle control (left-sided
paralysis)
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge about
protecting tissue integrity
c. Impaired skin integrity related to pressure over bony prominence (impaired
circulation)
d. Ineffective tissue perfusion related to sedentary lifestyle
ANS: C
Thexclient’sxmajorxproblemxisxtheximpairedxskinxintegrityxasxdemonstratedxbyxthexpresencexo
fxaxpressurexinjury.xThexnursexisxablextoxtreatxthexcausexofxalteredxcirculationxandxpressurex
byxfrequentlyxrepositioningxthexclient.xAlthoughxleft-
sidedxweaknessxisxaxproblemxforxthexclient,xthexnursexcannotxtreatxthexweakness.xThex“riskx
for”xdiagnosisxisxnotxappropriatexforxthisxclient,xwhoxalreadyxhasximpairedxtissuexintegrity.x
Thexclientxdoesxhavexineffectivextissuexperfusion,xbutxtheximpairedxskinxintegrityxdiagnosisx
indicatesxmorexclearlyxwhatxthexhealthxproblemxis.
DIF: CognitivexLevel:xApplication TOP:x NursingxProcess:xDiagnosis
6. Thexnursexcaringxforxaxclientxwithxanxinfectionxhasxaxnursingxdiagnosisxofxdeficientxfl
uidxvolumexrelatedxtoxexcessivexdiaphoresis.xWhichxofxthexfollowingxisxanxappropriate
xclientxoutcome?
a. Clientxhasxaxbalancedxintakexandxoutput.
b. Client’sxbeddingxisxchangedxwhenxitxbecomesxdamp.
, c. Clientxunderstandsxthexneedxforxincreasedxfluidxintake.
d. Client’sxskinxremainsxcoolxandxdryxthroughoutxhospitalization.
ANS:x A
Thisxstatementxgivesxmeasurablexdataxshowingxresolutionxofxthexproblemxofxdeficientxfluidx
volumexthatxwasxidentifiedxinxthexnursingxdiagnosisxstatement.xThexotherxstatementsxwouldx
notxindicatexthatxthexproblemxofxdeficientxfluidxvolumexwasxresolved.
DIF: CognitivexLevel:xApplication TOP:x NursingxProcess:xPlanning
7. Whichxofxthexfollowingxrepresentsxaxnursingxactivityxthatxisxcarriedxoutxduringxthexevaluati
onxphasexofxthexnursingxprocess?
a. Determiningxifxinterventionsxhavexbeenxeffectivexinxmeetingxclientxoutcomes
b. Documentingxthexnursingxcarexplanxinxthexprogressxnotesxinxthexmedicalxrecord
c. Decidingxwhetherxthexclient’sxhealthxproblemsxhavexbeenxcompletelyxresolved
d. Askingxthexclientxtoxevaluatexwhetherxthexnursingxcarexprovidedxwasxsatisfactory
ANS:x A
Evaluationxconsistsxofxdeterminingxwhetherxthexdesiredxclientxoutcomesxhavexbeenxmetxandxwhe
therxthexnursingxinterventionsxwerexappropriate.xThexotherxresponsesxdoxnotxdescribexthexevaluati
onxphase.
DIF: CognitivexLevel:xComprehension TOP:x NursingxProcess:xEvaluation
8. Whichxofxthexfollowingxwouldxthexnursexperformxduringxthexassessmentxphasexofxthexnursi
ngxprocess?
a. Obtainsxdataxwithxwhichxtoxdiagnosexclientxproblems
b. UsesxclientxdataxtoxdeveloN
p xp R
U SxIclient
r iori t y xnGursiBng.dCiagM
noses
c. Teachesxinterventionsxtoxrelieve N Txhealthxproblems
d. Assistsxthexclientxtoxidentifyxrealisticxoutcomesxtoxhealthxproblems
ANS:x A
Duringxthexassessmentxphase,xthexnursexgathersxinformationxaboutxthexclient.xThexotherxres
ponsesxarexexamplesxofxthexintervention,xdiagnosis,xandxplanningxphasesxofxthexnursingxproc
ess.
DIF: CognitivexLevel:xKnowledge TOP:x NursingxProcess:xAssessment
9. Whichxofxthexfollowingxisxanxexamplexofxaxcorrectlyxwrittenxnursingxdiagnosisxstatement?
a. Alteredxtissuexperfusionxrelatedxtoxheartxfailure
b. Riskxforximpairedxtissuexintegrityxrelatedxtoxsacralxredness
c. Ineffectivexcopingxrelatedxtoxinsufficientxsensexofxcontrol.
d. Alteredxurinaryxeliminationxrelatedxtoxurinaryxtractxinfection
ANS:x C
ThisxdiagnosisxstatementxincludesxaxNANDAxnursingxdiagnosisxandxanxetiologyxthatxdescrib
esxaxclient’sxresponsextoxaxhealthxproblemxthatxcanxbextreatedxbyxnursing.xThexusexofxaxmed
icalxdiagnosisx(asxinxthexresponsesxbeginningx“Alteredxtissuexperfusion”xandx“Alteredxurina
ryxelimination”)xisxnotxappropriate.xThexresponsexbeginningx“Riskxforximpairedxtissuexinteg
rity”xusesxthexdefiningxcharacteristicsxasxthexetiology.
DIF: CognitivexLevel:xComprehension TOP:x NursingxProcess:xDiagnosis
