TEST BANK
k
,Chapter k01:kIntroductionktokMedical-
Surgical kNursing kPractice kinkCanadakLewis:kMedical-
Surgical kNursing kinkCanada,k4thkCanadiankEdition
MULTIPLEkCHOICE
1. Whenkcaringk fork clientsk usingkevidence-
informedk practice,k whichk ofkthek followingkdoesk thek nursek use?
a. Clinicalk judgementk basedk onk experience
b. Evidencek fromk ak clinicalk researchk study
c. Thekbestk availablek evidencek tok guidek clinicalk expertise
d. Evaluationk ofk datak showingk thatk thek clientk outcomesk arek met
ANS:k C
Evidence-
informedk nursingk practicek isk ak continuousk interactivek processk involvingk thek explicit,k conscienti
ous,kandkjudiciousk considerationk ofkthek bestk availablek evidencektok providek care.k Fourk primaryk ele
mentsk are:k (a)k clinicalk state,k setting,k andk circumstances;k (b)k clientk preferencesk andk actions;k (c)k b
estkresearchk evidence;k andk (d)k healthk carek resources.kClinicalk judgementk basedk onk thek nurse’sk cli
nicalk experiencek isk partk ofk EIP,k butk clinicalk decisionk makingk alsok shouldk incorporatek currentk res
earchk andk research-
basedk guidelines.k Evidencek fromk onek clinicalk researchk studyk doesk notk providek ank adequatek subs
tantiationk fork interventions.k Evaluationk ofk clientk outcomesk isk important,k butk interventionsk shoul
dk bek basedk onk researchk fromk randomizedk controlk studiesk withk ak largek numberk ofk subjects.
DIF: Cognitivek Level:k Comprehension TOP:k Nursingk Process:k Planning
2. Whichk ofk thek followingk bestk e xp l a in s the n u r se s ’ p r i mar y k usek ofk thek nursingk processk whenkp
N R I G B .C M
rovidingk carek tok clients? UkSkNkT O
a. Tokexplaink nursingk interventionsk tok otherk healthk carek professionals
b. Ask ak problem-solvingk toolk tok identifykandk treatk clients’k healthk carek needs
c. Ask ak scientific-basedk processk ofk diagnosingk thek client’sk healthk carek problems
d. Tok establishk nursingk theoryk thatk incorporatesk thek biopsychosocialk naturek ofk humans
ANS:k B
Thek nursingk processk isk ank assertivek problem-
solvingk approachk tok thek identificationk andk treatmentk ofk clients’k problems.k Diagnosisk isk onlyk on
ek phasek ofk thek nursingk process.k Thek primaryk usekofk thek nursingk processk isk ink clientk care,k notk tok es
tablishk nursingk theorykork explaink nursingk interventionsk tok otherk healthk carek professionals.
DIF: Cognitivek Level:k Comprehension TOP:k Nursingk Process:k Implementation
3. Thek nursek isk caringk fork ak criticallyk illk clientk ink thek intensivek carek unitk andk plansk ank everyk2-
hourk turningk schedulek tok preventk skink breakdown.k Whichk typek ofk nursingk functionk isk demonstra
tedk withk thisk turningk schedule?
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS:k D
, Whenk implementingk collaborativek nursingk actions,k thek nursek isk responsiblek primarilyk fork monit
oringk fork complicationsk ofk acutek illnessk ork providingk carek tok preventk ork treatk complications.k Ind
ependentk nursingk actionsk arek focusedk onk healthk promotion,k illnessk prevention,k andk clientk advoc
acy.k Ak dependentk actionk wouldk requirek ak physiciank orderk tok implement.k Cooperativek nursingk fu
nctionsk areknotk describedk ask onekofkthek formalk nursingk functions.
DIF: Cognitivek Level:k Application TOP:k Nursingk Process:k Implementation
4. Thek nursek isk caringk fork ak clientk whok hask beenk admittedk tok thek hospitalk fork surgeryk andk tellsk thek n
urse,k “Ik dok notk feelk rightk aboutk leavingk myk childrenk withk myk neighbour.”k Whichk actionk shouldk
thek nursek takek next?
a. Reassurek thek clientk thatk thesek feelingsk arek commonk fork parents.
b. Havek thek clientk callk thek childrenk tok ensurek thatk theyk arek doingk well.
c. Callk thek neighbourk tok determinek whetherk adequatek childcarek isk beingk provided.
d. Gatherkmorek datak aboutk thek client’sk feelingsk aboutk thek childcarek arrangements.
ANS:k D
Sincek ak completek assessmentk isk necessaryk ink orderk tok identifyk ak problemk andk choosek ank appropr
iatek intervention,k thek nurse’sk firstk actionk shouldk bek tok obtaink morek information.k Thek otherkactio
nsk maykbek appropriate,k butk morek assessmentk isk neededk beforekthek bestk interventionk cank bek chose
n.
DIF: Cognitivek Level:k Application TOP:k Nursingk Process:k Assessment
5. Thek nursek isk caringk fork ak clientk whok hask left-
sidedk paralysisk ask thek resultk ofk ak strokek andk assessesk ak pressurek injuryk onk thek client’sk leftk
hip.k Whichk ofk thek followingk isN kR kI kG kB.C kM
k thek mostk appropriatek nursingk diagnosisk fUo r ktS
h is k cNlienTt
? O
a. Impairedkphysicalk mobilitykrelatedk tok decreasek ink musclek controlk (left-sided
paralysis)
b. Riskk fork impairedk tissuek integritykask evidencedk byk insufficientk knowledgek aboutk
protectingk tissuek integrity
c. Impairedkskink integritykrelatedk tok pressurekoverkbonykprominencek (impairedk
circulation)
d. Ineffectivek tissuek perfusionk relatedk tok sedentaryk lifestyle
ANS:k C
Thek client’sk majorkproblemk isk thek impairedk skink integrityk ask demonstratedk byk thekpresencek ofk ak p
ressurek injury.k Thek nursek isk ablek tok treatk thek causek ofk alteredk circulationk andk pressurek byk freque
ntlyk repositioningk thek client.k Althoughk left-
sidedk weaknessk isk ak problemk fork thek client,k thek nursek cannotk treatk thek weakness.k Thek “riskk for”k
diagnosisk isk notk appropriatek fork thisk client,k whok alreadyk hask impairedk tissuek integrity.k Thek clien
tk doesk havek ineffectivek tissuek perfusion,k butk thek impairedk skink integrityk diagnosisk indicatesk mor
ek clearlyk whatk thek healthk problemk is.
DIF: Cognitivek Level:k Application TOP:k Nursingk Process:k Diagnosis
6. Thek nursek caringk fork ak clientk withk ank infectionk hask ak nursingk diagnosisk ofk deficientk fluidk v
olumekrelatedk tok excessivekdiaphoresis.k Whichk ofkthek followingk isk ank appropriatekclientk o
utcome?
a. Clientk hask ak balancedk intakek andk output.
b. Client’sk beddingk isk changedk whenk itk becomesk damp.
, c. Clientk understandsk thek needk fork increasedk fluidk intake.
d. Client’sk skink remainsk coolk andk dryk throughoutk hospitalization.
ANS:k A
Thisk statementk givesk measurablek datak showingk resolutionk ofk thek problemk ofk deficientk fluidk volu
mek thatk wask identifiedk ink theknursingkdiagnosisk statement.k Thek otherk statementsk wouldk notk indic
atek thatk thek problemk ofk deficientk fluidk volumek wask resolved.
DIF: Cognitivek Level:k Application TOP:k Nursingk Process:k Planning
7. Whichk ofk thek followingk representsk aknursingkactivitykthatk isk carriedk outk duringk thek evaluationk p
hasek ofk thek nursingk process?
a. Determiningk ifk interventionsk havek beenk effectivek ink meetingk clientk outcomes
b. Documentingkthek nursingk carek plank ink thek progressk notesk ink thek medicalk record
c. Decidingkwhetherk thek client’sk healthk problemsk havek beenk completelyk resolved
d. Askingkthek clientk tok evaluatek whetherk thek nursingk carek providedk wask satisfactory
ANS:k A
Evaluationk consistsk ofk determiningk whetherk thek desiredk clientk outcomesk havek beenk metk andk whether
ktheknursingk interventionsk werekappropriate.k Thek otherk responsesk dok notk describek thek evaluationk phas
e.
DIF: Cognitivek Level:k Comprehension TOP:k Nursingk Process:k Evaluation
8. Whichk ofk thek followingk wouldk thek nursekperformk duringk thek assessmentk phasek ofk thek nursingk p
rocess?
a. Obtainsk datak withk whichk tok diagnosek clientk problems
b. Usesk clientk datak tok develoN
pk p R
r io r I
i ty k nGursiBng.dCiagMnoses
c. Teachesk interventionsk tok relieve UkSkkclient
NkT khealthkproblems
d. Assistsk thek clientk tok identifyk realistick outcomesk tok healthk problems
ANS:k A
Duringk thek assessmentk phase,k thek nursek gathersk informationk aboutk thek client.k Thek otherk respons
esk arekexamplesk ofkthek intervention,k diagnosis,k andk planningkphasesk ofk thek nursingk process.
DIF: Cognitivek Level:k Knowledge TOP:k Nursingk Process:k Assessment
9. Whichk ofk thek followingk isk ank examplek ofk ak correctlyk writtenk nursingk diagnosisk statement?
a. Alteredktissuek perfusionk relatedk tok heartk failure
b. Riskk forkimpairedk tissuek integritykrelatedk tok sacralk redness
c. Ineffectivek copingkrelatedk tok insufficientk sensek ofk control.
d. Alteredkurinarykeliminationk relatedk tok urinaryktractk infection
ANS:k C
Thisk diagnosisk statementk includesk akNANDAk nursingkdiagnosisk andkank etiologykthatk describesk ak
client’sk responsek tok ak healthk problemk thatk cank bek treatedk byk nursing.k Thek usek ofk ak medicalk diagn
osisk (ask ink thek responsesk beginningk “Alteredk tissuek perfusion”k andk “Alteredk urinaryk elimination
”)k isk notk appropriate.k Thek responsek beginningk “Riskk fork impairedk tissuek integrity”k usesk thek defi
ningk characteristicsk ask thek etiology.
DIF: Cognitivek Level:k Comprehension TOP:k Nursingk Process:k Diagnosis
k
,Chapter k01:kIntroductionktokMedical-
Surgical kNursing kPractice kinkCanadakLewis:kMedical-
Surgical kNursing kinkCanada,k4thkCanadiankEdition
MULTIPLEkCHOICE
1. Whenkcaringk fork clientsk usingkevidence-
informedk practice,k whichk ofkthek followingkdoesk thek nursek use?
a. Clinicalk judgementk basedk onk experience
b. Evidencek fromk ak clinicalk researchk study
c. Thekbestk availablek evidencek tok guidek clinicalk expertise
d. Evaluationk ofk datak showingk thatk thek clientk outcomesk arek met
ANS:k C
Evidence-
informedk nursingk practicek isk ak continuousk interactivek processk involvingk thek explicit,k conscienti
ous,kandkjudiciousk considerationk ofkthek bestk availablek evidencektok providek care.k Fourk primaryk ele
mentsk are:k (a)k clinicalk state,k setting,k andk circumstances;k (b)k clientk preferencesk andk actions;k (c)k b
estkresearchk evidence;k andk (d)k healthk carek resources.kClinicalk judgementk basedk onk thek nurse’sk cli
nicalk experiencek isk partk ofk EIP,k butk clinicalk decisionk makingk alsok shouldk incorporatek currentk res
earchk andk research-
basedk guidelines.k Evidencek fromk onek clinicalk researchk studyk doesk notk providek ank adequatek subs
tantiationk fork interventions.k Evaluationk ofk clientk outcomesk isk important,k butk interventionsk shoul
dk bek basedk onk researchk fromk randomizedk controlk studiesk withk ak largek numberk ofk subjects.
DIF: Cognitivek Level:k Comprehension TOP:k Nursingk Process:k Planning
2. Whichk ofk thek followingk bestk e xp l a in s the n u r se s ’ p r i mar y k usek ofk thek nursingk processk whenkp
N R I G B .C M
rovidingk carek tok clients? UkSkNkT O
a. Tokexplaink nursingk interventionsk tok otherk healthk carek professionals
b. Ask ak problem-solvingk toolk tok identifykandk treatk clients’k healthk carek needs
c. Ask ak scientific-basedk processk ofk diagnosingk thek client’sk healthk carek problems
d. Tok establishk nursingk theoryk thatk incorporatesk thek biopsychosocialk naturek ofk humans
ANS:k B
Thek nursingk processk isk ank assertivek problem-
solvingk approachk tok thek identificationk andk treatmentk ofk clients’k problems.k Diagnosisk isk onlyk on
ek phasek ofk thek nursingk process.k Thek primaryk usekofk thek nursingk processk isk ink clientk care,k notk tok es
tablishk nursingk theorykork explaink nursingk interventionsk tok otherk healthk carek professionals.
DIF: Cognitivek Level:k Comprehension TOP:k Nursingk Process:k Implementation
3. Thek nursek isk caringk fork ak criticallyk illk clientk ink thek intensivek carek unitk andk plansk ank everyk2-
hourk turningk schedulek tok preventk skink breakdown.k Whichk typek ofk nursingk functionk isk demonstra
tedk withk thisk turningk schedule?
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS:k D
, Whenk implementingk collaborativek nursingk actions,k thek nursek isk responsiblek primarilyk fork monit
oringk fork complicationsk ofk acutek illnessk ork providingk carek tok preventk ork treatk complications.k Ind
ependentk nursingk actionsk arek focusedk onk healthk promotion,k illnessk prevention,k andk clientk advoc
acy.k Ak dependentk actionk wouldk requirek ak physiciank orderk tok implement.k Cooperativek nursingk fu
nctionsk areknotk describedk ask onekofkthek formalk nursingk functions.
DIF: Cognitivek Level:k Application TOP:k Nursingk Process:k Implementation
4. Thek nursek isk caringk fork ak clientk whok hask beenk admittedk tok thek hospitalk fork surgeryk andk tellsk thek n
urse,k “Ik dok notk feelk rightk aboutk leavingk myk childrenk withk myk neighbour.”k Whichk actionk shouldk
thek nursek takek next?
a. Reassurek thek clientk thatk thesek feelingsk arek commonk fork parents.
b. Havek thek clientk callk thek childrenk tok ensurek thatk theyk arek doingk well.
c. Callk thek neighbourk tok determinek whetherk adequatek childcarek isk beingk provided.
d. Gatherkmorek datak aboutk thek client’sk feelingsk aboutk thek childcarek arrangements.
ANS:k D
Sincek ak completek assessmentk isk necessaryk ink orderk tok identifyk ak problemk andk choosek ank appropr
iatek intervention,k thek nurse’sk firstk actionk shouldk bek tok obtaink morek information.k Thek otherkactio
nsk maykbek appropriate,k butk morek assessmentk isk neededk beforekthek bestk interventionk cank bek chose
n.
DIF: Cognitivek Level:k Application TOP:k Nursingk Process:k Assessment
5. Thek nursek isk caringk fork ak clientk whok hask left-
sidedk paralysisk ask thek resultk ofk ak strokek andk assessesk ak pressurek injuryk onk thek client’sk leftk
hip.k Whichk ofk thek followingk isN kR kI kG kB.C kM
k thek mostk appropriatek nursingk diagnosisk fUo r ktS
h is k cNlienTt
? O
a. Impairedkphysicalk mobilitykrelatedk tok decreasek ink musclek controlk (left-sided
paralysis)
b. Riskk fork impairedk tissuek integritykask evidencedk byk insufficientk knowledgek aboutk
protectingk tissuek integrity
c. Impairedkskink integritykrelatedk tok pressurekoverkbonykprominencek (impairedk
circulation)
d. Ineffectivek tissuek perfusionk relatedk tok sedentaryk lifestyle
ANS:k C
Thek client’sk majorkproblemk isk thek impairedk skink integrityk ask demonstratedk byk thekpresencek ofk ak p
ressurek injury.k Thek nursek isk ablek tok treatk thek causek ofk alteredk circulationk andk pressurek byk freque
ntlyk repositioningk thek client.k Althoughk left-
sidedk weaknessk isk ak problemk fork thek client,k thek nursek cannotk treatk thek weakness.k Thek “riskk for”k
diagnosisk isk notk appropriatek fork thisk client,k whok alreadyk hask impairedk tissuek integrity.k Thek clien
tk doesk havek ineffectivek tissuek perfusion,k butk thek impairedk skink integrityk diagnosisk indicatesk mor
ek clearlyk whatk thek healthk problemk is.
DIF: Cognitivek Level:k Application TOP:k Nursingk Process:k Diagnosis
6. Thek nursek caringk fork ak clientk withk ank infectionk hask ak nursingk diagnosisk ofk deficientk fluidk v
olumekrelatedk tok excessivekdiaphoresis.k Whichk ofkthek followingk isk ank appropriatekclientk o
utcome?
a. Clientk hask ak balancedk intakek andk output.
b. Client’sk beddingk isk changedk whenk itk becomesk damp.
, c. Clientk understandsk thek needk fork increasedk fluidk intake.
d. Client’sk skink remainsk coolk andk dryk throughoutk hospitalization.
ANS:k A
Thisk statementk givesk measurablek datak showingk resolutionk ofk thek problemk ofk deficientk fluidk volu
mek thatk wask identifiedk ink theknursingkdiagnosisk statement.k Thek otherk statementsk wouldk notk indic
atek thatk thek problemk ofk deficientk fluidk volumek wask resolved.
DIF: Cognitivek Level:k Application TOP:k Nursingk Process:k Planning
7. Whichk ofk thek followingk representsk aknursingkactivitykthatk isk carriedk outk duringk thek evaluationk p
hasek ofk thek nursingk process?
a. Determiningk ifk interventionsk havek beenk effectivek ink meetingk clientk outcomes
b. Documentingkthek nursingk carek plank ink thek progressk notesk ink thek medicalk record
c. Decidingkwhetherk thek client’sk healthk problemsk havek beenk completelyk resolved
d. Askingkthek clientk tok evaluatek whetherk thek nursingk carek providedk wask satisfactory
ANS:k A
Evaluationk consistsk ofk determiningk whetherk thek desiredk clientk outcomesk havek beenk metk andk whether
ktheknursingk interventionsk werekappropriate.k Thek otherk responsesk dok notk describek thek evaluationk phas
e.
DIF: Cognitivek Level:k Comprehension TOP:k Nursingk Process:k Evaluation
8. Whichk ofk thek followingk wouldk thek nursekperformk duringk thek assessmentk phasek ofk thek nursingk p
rocess?
a. Obtainsk datak withk whichk tok diagnosek clientk problems
b. Usesk clientk datak tok develoN
pk p R
r io r I
i ty k nGursiBng.dCiagMnoses
c. Teachesk interventionsk tok relieve UkSkkclient
NkT khealthkproblems
d. Assistsk thek clientk tok identifyk realistick outcomesk tok healthk problems
ANS:k A
Duringk thek assessmentk phase,k thek nursek gathersk informationk aboutk thek client.k Thek otherk respons
esk arekexamplesk ofkthek intervention,k diagnosis,k andk planningkphasesk ofk thek nursingk process.
DIF: Cognitivek Level:k Knowledge TOP:k Nursingk Process:k Assessment
9. Whichk ofk thek followingk isk ank examplek ofk ak correctlyk writtenk nursingk diagnosisk statement?
a. Alteredktissuek perfusionk relatedk tok heartk failure
b. Riskk forkimpairedk tissuek integritykrelatedk tok sacralk redness
c. Ineffectivek copingkrelatedk tok insufficientk sensek ofk control.
d. Alteredkurinarykeliminationk relatedk tok urinaryktractk infection
ANS:k C
Thisk diagnosisk statementk includesk akNANDAk nursingkdiagnosisk andkank etiologykthatk describesk ak
client’sk responsek tok ak healthk problemk thatk cank bek treatedk byk nursing.k Thek usek ofk ak medicalk diagn
osisk (ask ink thek responsesk beginningk “Alteredk tissuek perfusion”k andk “Alteredk urinaryk elimination
”)k isk notk appropriate.k Thek responsek beginningk “Riskk fork impairedk tissuek integrity”k usesk thek defi
ningk characteristicsk ask thek etiology.
DIF: Cognitivek Level:k Comprehension TOP:k Nursingk Process:k Diagnosis
