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 N
e x p lRa i n sIt h eGn u B
r s. ‘ prM
e sC imary use of the nursing process when
providing care to clients?
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 nimplementing ncollaborative nnursing nactions, nthe nnurse nis nresponsible nprimarily nfor
nmonitoring nfor ncomplications nof nacute nillness nor nproviding ncare nto nprevent nor ntreat
ncomplications. nIndependent nnursing nactions nare nfocused non nhealth npromotion, nillness
nprevention, nand nclient nadvocacy. nA ndependent naction nwould nrequire na nphysician norder nto
nimplement. nCooperative nnursing nfunctions nare nnot ndescribed nas none nof nthe nformal nnursing
nfunctions.
DIF: Cognitive nLevel: nApplication TOP: n Nursing nProcess: nImplementation
4. The nnurse nis ncaring nfor na nclient nwho nhas nbeen nadmitted nto nthe nhospital nfor nsurgery nand ntells
the nnurse, n―I ndo nnot nfeel nright nabout nleaving nmy nchildren nwith nmy nneighbour.‖ nWhich
n
naction nshould nthe nnurse ntake nnext?
a. Reassure nthe nclient nthat nthese nfeelings nare ncommon nfor nparents.
b. Have nthe nclient ncall nthe nchildren nto nensure nthat nthey nare ndoing nwell.
c. Call nthe nneighbour nto ndetermine nwhether nadequate nchildcare nis nbeing nprovided.
d. Gather nmore ndata nabout nthe nclient‘s nfeelings nabout nthe nchildcare narrangements.
ANS: n D
Since na ncomplete nassessment nis nnecessary nin norder nto nidentify na nproblem nand nchoose nan
nappropriate nintervention, nthe nnurse‘s nfirst naction nshould nbe nto nobtain nmore ninformation. nThe
nother nactions nmay nbe nappropriate, nbut nmore nassessment nis nneeded nbefore nthe nbest
nintervention ncan nbe nchosen.
DIF: Cognitive nLevel: nApplication TOP: n Nursing nProcess: nAssessment
5. The nnurse nis ncaring nfor na nclient nwho nhas nleft-sided nparalysis nas nthe nresult nof na nstroke nand
assesses n a n pressure n injury n on the clie nt‘s left h ip . n W hich n of n the n following n is n the n most
appropriate n nursing n diagnosisNn fUoR hI
r ntS Gl i e nT
i s n cN Bt ?.OC M
a. Impaired nphysical nmobility nrelated nto ndecrease nin nmuscle ncontrol n(left-
sided nparalysis)
b. Risk nfor nimpaired ntissue nintegrity nas nevidenced nby ninsufficient nknowledge
nabout nprotecting ntissue nintegrity
c. Impaired nskin nintegrity nrelated nto npressure nover nbony nprominence
n(impaired ncirculation)
d. Ineffective ntissue nperfusion nrelated nto nsedentary nlifestyle
ANS: n C
The nclient‘s nmajor nproblem nis nthe nimpaired nskin nintegrity nas ndemonstrated nby nthe npresence nof
na npressure ninjury. nThe nnurse nis nable nto ntreat nthe ncause nof naltered ncirculation nand npressure nby
nfrequently nrepositioning nthe nclient. nAlthough nleft-sided nweakness nis na nproblem nfor nthe
nclient,
the nnurse ncannot ntreat nthe nweakness. nThe n―risk nfor‖ ndiagnosis nis nnot nappropriate nfor nthis
nclient, nwho nalready nhas nimpaired ntissue nintegrity. nThe nclient ndoes nhave nineffective ntissue
nperfusion, nbut nthe nimpaired nskin nintegrity ndiagnosis nindicates nmore nclearly nwhat nthe nhealth
nproblem nis.
DIF: Cognitive nLevel: nApplication TOP: n Nursing nProcess: nDiagnosis
6. The nnurse ncaring nfor na nclient nwith nan ninfection nhas na nnursing ndiagnosis nof ndeficient
nfluid nvolume nrelated nto nexcessive ndiaphoresis. nWhich nof nthe nfollowing nis nan
appropriate nclient noutcome?
n
a. Client nhas na nbalanced nintake nand noutput.
b. Client‘s nbedding nis nchanged nwhen nit nbecomes ndamp.
, c. Client nunderstands nthe nneed nfor nincreased nfluid nintake.
d. Client‘s nskin nremains ncool nand ndry nthroughout nhospitalization.
ANS: n A
This nstatement ngives nmeasurable ndata nshowing nresolution nof nthe nproblem nof ndeficient nfluid
nvolume nthat nwas nidentified nin nthe nnursing ndiagnosis nstatement. nThe nother nstatements nwould
nnot nindicate nthat nthe nproblem nof ndeficient nfluid nvolume nwas nresolved.
DIF: Cognitive nLevel: nApplication TOP: n Nursing nProcess: nPlanning
7. Which nof nthe nfollowing nrepresents na nnursing nactivity nthat nis ncarried nout nduring nthe
nevaluation nphase nof nthe nnursing nprocess?
a. Determining nif ninterventions nhave nbeen neffective nin nmeeting nclient noutcomes
b. Documenting nthe nnursing ncare nplan nin nthe nprogress nnotes nin nthe nmedical nrecord
c. Deciding nwhether nthe nclient‘s nhealth nproblems nhave nbeen ncompletely nresolved
d. Asking nthe nclient nto nevaluate nwhether nthe nnursing ncare nprovided nwas nsatisfactory
ANS: n A
Evaluation nconsists nof ndetermining nwhether nthe ndesired nclient noutcomes nhave nbeen nmet nand
nwhether nthe nnursing ninterventions nwere nappropriate. nThe nother nresponses ndo nnot ndescribe nthe
nevaluation nphase.
DIF: Cognitive nLevel: nComprehension TOP: n Nursing nProcess: nEvaluation
8. Which nof nthe nfollowing nwould nthe nnurse nperform nduring nthe nassessment nphase nof nthe
nursing nprocess?
n
a. Obtains ndata nwith nwhich nto ndiagnose nclient nproblems
b. Uses n client n data nto n develoNp npUR Ity n nGursB
nS nN nT
riori in.
g nC
dOiagMnoses
c. Teaches ninterventions nto nrelieve nclient nhealth nproblems
d. Assists nthe nclient nto nidentify nrealistic noutcomes nto nhealth nproblems
ANS: n A
During nthe nassessment nphase, nthe nnurse ngathers ninformation nabout nthe nclient. nThe nother
nresponses nare nexamples nof nthe nintervention, ndiagnosis, nand nplanning nphases nof nthe nnursing
nprocess.
DIF: Cognitive nLevel: nKnowledge TOP: n Nursing nProcess: nAssessment
9. Which nof nthe nfollowing nis nan nexample nof na ncorrectly nwritten nnursing ndiagnosis nstatement?
a. Altered ntissue nperfusion nrelated nto nheart nfailure
b. Risk nfor nimpaired ntissue nintegrity nrelated nto nsacral nredness
c. Ineffective ncoping nrelated nto ninsufficient nsense nof ncontrol.
d. Altered nurinary nelimination nrelated nto nurinary ntract ninfection
ANS: n C
This ndiagnosis nstatement nincludes na nNANDA nnursing ndiagnosis nand nan netiology nthat
ndescribes na nclient‘s nresponse nto na nhealth nproblem nthat ncan nbe ntreated nby nnursing. nThe nuse nof
na nmedical ndiagnosis n(as nin nthe nresponses nbeginning n―Altered ntissue nperfusion‖ nand n―Altered
nurinary
elimination‖) nis nnot nappropriate. nThe nresponse nbeginning n―Risk nfor nimpaired ntissue nintegrity‖
uses nthe ndefining ncharacteristics nas nthe netiology.
DIF: Cognitive nLevel: nComprehension TOP: n Nursing nProcess: nDiagnosis
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 N
e x p lRa i n sIt h eGn u B
r s. ‘ prM
e sC imary use of the nursing process when
providing care to clients?
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 nimplementing ncollaborative nnursing nactions, nthe nnurse nis nresponsible nprimarily nfor
nmonitoring nfor ncomplications nof nacute nillness nor nproviding ncare nto nprevent nor ntreat
ncomplications. nIndependent nnursing nactions nare nfocused non nhealth npromotion, nillness
nprevention, nand nclient nadvocacy. nA ndependent naction nwould nrequire na nphysician norder nto
nimplement. nCooperative nnursing nfunctions nare nnot ndescribed nas none nof nthe nformal nnursing
nfunctions.
DIF: Cognitive nLevel: nApplication TOP: n Nursing nProcess: nImplementation
4. The nnurse nis ncaring nfor na nclient nwho nhas nbeen nadmitted nto nthe nhospital nfor nsurgery nand ntells
the nnurse, n―I ndo nnot nfeel nright nabout nleaving nmy nchildren nwith nmy nneighbour.‖ nWhich
n
naction nshould nthe nnurse ntake nnext?
a. Reassure nthe nclient nthat nthese nfeelings nare ncommon nfor nparents.
b. Have nthe nclient ncall nthe nchildren nto nensure nthat nthey nare ndoing nwell.
c. Call nthe nneighbour nto ndetermine nwhether nadequate nchildcare nis nbeing nprovided.
d. Gather nmore ndata nabout nthe nclient‘s nfeelings nabout nthe nchildcare narrangements.
ANS: n D
Since na ncomplete nassessment nis nnecessary nin norder nto nidentify na nproblem nand nchoose nan
nappropriate nintervention, nthe nnurse‘s nfirst naction nshould nbe nto nobtain nmore ninformation. nThe
nother nactions nmay nbe nappropriate, nbut nmore nassessment nis nneeded nbefore nthe nbest
nintervention ncan nbe nchosen.
DIF: Cognitive nLevel: nApplication TOP: n Nursing nProcess: nAssessment
5. The nnurse nis ncaring nfor na nclient nwho nhas nleft-sided nparalysis nas nthe nresult nof na nstroke nand
assesses n a n pressure n injury n on the clie nt‘s left h ip . n W hich n of n the n following n is n the n most
appropriate n nursing n diagnosisNn fUoR hI
r ntS Gl i e nT
i s n cN Bt ?.OC M
a. Impaired nphysical nmobility nrelated nto ndecrease nin nmuscle ncontrol n(left-
sided nparalysis)
b. Risk nfor nimpaired ntissue nintegrity nas nevidenced nby ninsufficient nknowledge
nabout nprotecting ntissue nintegrity
c. Impaired nskin nintegrity nrelated nto npressure nover nbony nprominence
n(impaired ncirculation)
d. Ineffective ntissue nperfusion nrelated nto nsedentary nlifestyle
ANS: n C
The nclient‘s nmajor nproblem nis nthe nimpaired nskin nintegrity nas ndemonstrated nby nthe npresence nof
na npressure ninjury. nThe nnurse nis nable nto ntreat nthe ncause nof naltered ncirculation nand npressure nby
nfrequently nrepositioning nthe nclient. nAlthough nleft-sided nweakness nis na nproblem nfor nthe
nclient,
the nnurse ncannot ntreat nthe nweakness. nThe n―risk nfor‖ ndiagnosis nis nnot nappropriate nfor nthis
nclient, nwho nalready nhas nimpaired ntissue nintegrity. nThe nclient ndoes nhave nineffective ntissue
nperfusion, nbut nthe nimpaired nskin nintegrity ndiagnosis nindicates nmore nclearly nwhat nthe nhealth
nproblem nis.
DIF: Cognitive nLevel: nApplication TOP: n Nursing nProcess: nDiagnosis
6. The nnurse ncaring nfor na nclient nwith nan ninfection nhas na nnursing ndiagnosis nof ndeficient
nfluid nvolume nrelated nto nexcessive ndiaphoresis. nWhich nof nthe nfollowing nis nan
appropriate nclient noutcome?
n
a. Client nhas na nbalanced nintake nand noutput.
b. Client‘s nbedding nis nchanged nwhen nit nbecomes ndamp.
, c. Client nunderstands nthe nneed nfor nincreased nfluid nintake.
d. Client‘s nskin nremains ncool nand ndry nthroughout nhospitalization.
ANS: n A
This nstatement ngives nmeasurable ndata nshowing nresolution nof nthe nproblem nof ndeficient nfluid
nvolume nthat nwas nidentified nin nthe nnursing ndiagnosis nstatement. nThe nother nstatements nwould
nnot nindicate nthat nthe nproblem nof ndeficient nfluid nvolume nwas nresolved.
DIF: Cognitive nLevel: nApplication TOP: n Nursing nProcess: nPlanning
7. Which nof nthe nfollowing nrepresents na nnursing nactivity nthat nis ncarried nout nduring nthe
nevaluation nphase nof nthe nnursing nprocess?
a. Determining nif ninterventions nhave nbeen neffective nin nmeeting nclient noutcomes
b. Documenting nthe nnursing ncare nplan nin nthe nprogress nnotes nin nthe nmedical nrecord
c. Deciding nwhether nthe nclient‘s nhealth nproblems nhave nbeen ncompletely nresolved
d. Asking nthe nclient nto nevaluate nwhether nthe nnursing ncare nprovided nwas nsatisfactory
ANS: n A
Evaluation nconsists nof ndetermining nwhether nthe ndesired nclient noutcomes nhave nbeen nmet nand
nwhether nthe nnursing ninterventions nwere nappropriate. nThe nother nresponses ndo nnot ndescribe nthe
nevaluation nphase.
DIF: Cognitive nLevel: nComprehension TOP: n Nursing nProcess: nEvaluation
8. Which nof nthe nfollowing nwould nthe nnurse nperform nduring nthe nassessment nphase nof nthe
nursing nprocess?
n
a. Obtains ndata nwith nwhich nto ndiagnose nclient nproblems
b. Uses n client n data nto n develoNp npUR Ity n nGursB
nS nN nT
riori in.
g nC
dOiagMnoses
c. Teaches ninterventions nto nrelieve nclient nhealth nproblems
d. Assists nthe nclient nto nidentify nrealistic noutcomes nto nhealth nproblems
ANS: n A
During nthe nassessment nphase, nthe nnurse ngathers ninformation nabout nthe nclient. nThe nother
nresponses nare nexamples nof nthe nintervention, ndiagnosis, nand nplanning nphases nof nthe nnursing
nprocess.
DIF: Cognitive nLevel: nKnowledge TOP: n Nursing nProcess: nAssessment
9. Which nof nthe nfollowing nis nan nexample nof na ncorrectly nwritten nnursing ndiagnosis nstatement?
a. Altered ntissue nperfusion nrelated nto nheart nfailure
b. Risk nfor nimpaired ntissue nintegrity nrelated nto nsacral nredness
c. Ineffective ncoping nrelated nto ninsufficient nsense nof ncontrol.
d. Altered nurinary nelimination nrelated nto nurinary ntract ninfection
ANS: n C
This ndiagnosis nstatement nincludes na nNANDA nnursing ndiagnosis nand nan netiology nthat
ndescribes na nclient‘s nresponse nto na nhealth nproblem nthat ncan nbe ntreated nby nnursing. nThe nuse nof
na nmedical ndiagnosis n(as nin nthe nresponses nbeginning n―Altered ntissue nperfusion‖ nand n―Altered
nurinary
elimination‖) nis nnot nappropriate. nThe nresponse nbeginning n―Risk nfor nimpaired ntissue nintegrity‖
uses nthe ndefining ncharacteristics nas nthe netiology.
DIF: Cognitive nLevel: nComprehension TOP: n Nursing nProcess: nDiagnosis
