MEDICAL SURGICAL NURSING CARE 3RD EDITION BY BURKE

Chapter 01. Nursing in the 21st Century MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question. 1) The nurse is preparing to conduct an assessment on a client in the clinic setting. The client asks the nurse why nurses assess when the physician will as well. The nurse responds with which of the following? A) The physician will treat with procedures. B) The physician does not really assess. C) The nurse treats the clientʹs response to illness. D) The nurse assesses to determine needed medications. Answer: C Explanation: A) The physician does treat with procedures, but this does not answer the clientʹs question. B) The physician assesses the client based on the clientʹs need. C) The nurse assesses in order to provide nursing care based on the client response to illness. D) The physician, not the nurse, orders medications. Cognitive Level: Knowledge Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome: 1-1 MEDICAL SURGICAL NURSING CARE 3RD EDITION BY BURKE 2) The nurse is conducting an assessment of a 65-year-old client who has come for an annual assessment. The nurse expects to give the client immunizations as a part of: (Select all that apply.) A) Promoting client health. B) Caring for the clientʹs illness. C) Maintaining the clientʹs health. D) Alleviating the clientʹs suffering. E) Caring for the clientʹs family. Answer: A, C Explanation: A) Providing immunizations is an example of promoting health. B) The client receiving immunizations is not generally ill. C) Immunizations help to maintain the clientʹs health status. D) The client having an annual assessment is usually not suffering. E) Immunizing a client is not an example of care of the family. Cognitive Level: Comprehension Client Need: Health Promotion and Maintenance Nursing Process: Planning Learning Outcome: 1-1 3) The nurse performs daily, routine equipment checks to detect possible malfunction. Which core competency is the nurse demonstrating with this action? A) Providing agency-centered care B) Working on an interdisciplinary team C) Using information technology D) Applying quality improvement principles Answer: D Explanation: A) Nurses provide patient-centered care. B) The nurse is functioning alone when inspecting equipment. C) Information technology is the use of computers during health care. D) Part of the responsibility of the nurse is to ensure the clientʹs safety by inspecting equipment used during care. This is a quality improvement principle. Cognitive Level: Knowledge Client Need: Safe, Effective Care Environment Nursing Process: Implementation Learning Outcome: 1-1 1 4) A client who is experiencing abdominal pain is being assessed by the Emergency Department nurse. The nurse asks the client to describe the pain and the clientʹs usual means of relieving pain. The nurse is providing: A) A nursing diagnosis. B) Client-centered care. C) Health promotion. D) Health maintenance. Answer: B Explanation: A) A nursing diagnosis is made after the assessment is completed. B) The nurse is providing client-centered care by asking the client about the perception of pain and the clientʹs usual methods of relief. C) Health promotion might include assisting the client to alter risk factors for a disease. D) Immunization is an example of health maintenance. Cognitive Level: Comprehension Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome: 1-2 5) The nurse is caring for an elderly client who lives with an extended family. The nurse plans to teach the client and family regarding safety issues for the client in the home. The nurse is: A) Providing disease management. B) Relieving pain and suffering. C) Adapting care to the needs of the client. D) Advocating for lifestyle changes for the client. Answer: C Explanation: A) There is no evidence that this client has a disease. B) Relieving pain and suffering might include administering pain medications. C) The nurse is adapting care by advocating for client safety in the home. D) Lifestyle changes would include issues such as diet changes or exercise. Cognitive Level: Comprehension Client Need: Safe, Effective Care Environment Nursing Process: Planning Learning Outcome: 1-2 6) The nurse is planning care for a client who is experiencing a chronic disease. The nurse asks the client about food preferences when discussing needed lifestyle changes. The nurse is providing client - centered care by: A) Allowing the client to assume the primary role in planning. B) Planning care for the client. C) Following the care ordered by the dietician. D) Assessing the clientʹs needs. Answer: A Explanation: A) The nurse is providing client centered-care by allowing the client to assume the primary role in the planning process. B) The nurse is planning care, but is including the client in the plan. C) The doctor orders the diet for the client. D) The nurse is planning care, not assessing. Cognitive Level: Comprehension Client Need: Health Promotion and Maintenance Nursing Process: Planning Learning Outcome: 1-2 2 7) A client is requesting a second opinion. The nurse who supports and promotes the clientʹs rights is acting as the clientʹs: A) Teacher. B) Supporter. C) Advisor. D) Advocate. Answer: D Explanation: A) The nurse assumes the role of teacher when providing the client with information. B) Supporting the client means that the nurse offers encouragement when the client makes decisions. C) Nurses are discouraged from advising the client. The role of the nurse is to present the available options and the consequences of each choice. D) As an advocate, the nurse protects the clientʹs right to self-determination, one of which is seeking a second opinion. Cognitive Level: Comprehension Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome: 1-3 8) A client is being discharged, and needs instructions on wound care. When planning to teach the client, the nurse should: A) Identify the clientʹs learning needs and advise the client on what to do. B) Provide pamphlets and videotapes for ongoing learning. C) Identify the clientʹs learning needs and learning ability. D) Identify the clientʹs problems and make the appropriate referral. Answer: C Explanation: A) The nurse is discouraged from advising the client. Decisions are made with the client. B) Providing pamphlets or videotapes would not meet the needs of a client who was blind or who is unable to read. C) As a teacher, the nurse first assesses the needs of the client and then determines the clientʹs ability to learn. D) The nurse is responsible for determining the learning needs of the client. In some instances, such as wound care, a referral may be made to a wound care nurse. However, the nurse giving care is responsible for the initial determination of needs and abilities. Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Planning