Medical Surgical Nursing 10th-Edition-
m m m
Lewis Test-Bank.
m m
,Chapter m01:mProfessional mNursing mPractice mLe
wis:mMedical-SurgicalmNursing,m10thmEdition
MULTIPLEmCHOICE
1. Themnursemcompletesmanmadmissionmdatabasemand mexplainsmthat mthemplanmof mcaremand mdischarge
mgoalsmwillmbemdeveloped mwithmthempatient’sminput.mThempatient mstates,m“How mismthismdifferent mfr
ommwhat mthemdoctormdoes?”mWhichmresponsemwould mbemmostmappropriatemformthemnursemtomma
ke?
a. “Themrolemof mthemnursemismtomadministermmedicationsmand mothermtreatmentsmprescrib
ed mbymyourmdoctor.”
b. “Themnurse’smjobmismtomhelpmthemdoctormbymcollectingminformationma
nd mcommunicatingmanymproblemsmthat moccur.”
c. “Nursesmperformmmanymof mthemsamemproceduresmasmthemdoctor,mbut mnursesmaremwi
thmthempatientsmformamlongermtimemthanmthemdoctor.”
d. “Inmadditionmtomcaringmformyoumwhilemyoumaremsick,mthemnursesmwillmassist myou
mtomdevelopmanmindividualized mplanmtommaintainmyourmhealth.”
ANS:m D
Thismresponsemismconsistent mwithmthemAmericanmNursesmAssociationm(ANA)mdefinitionmof mnursi
ng,mwhichmdescribesmthemrolemof mnursesminmpromotingmhealth.mThemothermresponsesmdescribemso
memof mthemdependent mand mcollaborativemfunctionsmof mthemnursingmrolembut mdomnot maccuratelymd
escribemthemnurse’smroleminmthemhealthmcarem system.
DIF: CognitivemLevel:mUnderstand m(comprehension) REF:m 3
TOP:m NursingmProcess:mImplementation MSC:m NCLEX:mSafemand mEffective mCaremEnvironment
2. Themnursemdescribesmtomamstudent mnursemhow mtomusemevidence-
based mpracticemguidelinesmwhenmcaringmformpatients.mWhichmstatement,mif mmadembymthemnur
se,mwould mbemthemmostmaccurate?
a. “Inferencesmfrommclinicalmresearchmstudiesmaremused masmamguide.”
b. “Patient mcaremismbased monmclinicalmjudgment,mexperience,mand mtraditions.”
c. “Datamaremevaluated mtomshow mthat mthempatient moutcomesmaremconsistentlymmet.”
d. “Recommendationsmarembased monmresearch,mclinicalmexpertise,mand mpatie
nt mpreferences.”
ANS:m D
Evidence-based mpracticem(EBP)mismthemusemof mthembest mresearch-
based mevidencemcombined mwithmclinicianmexpertise.mClinicalmjudgment mbased monmthemnurse’smcl
inicalmexperiencemismpart mof mEBP,mbut mclinicalmdecisionmmakingm should malsom incorporatemcurren
t mresearchmand mresearch-
based mguidelines.mEvaluationmof mpatient moutcomesmismimportant,mbut minterventionsmshould mbemb
ased monmresearchmfrommrandomized mcontrolmstudiesmwithmamlargemnumbermof msubjects.
DIF: CognitivemLevel:mRememberm(knowledge) REF:m 15
TOP:m NursingmProcess:mPlanning MSC:m NCLEX:mSafemand mEffective mCaremEnvironment
3. Themnursemteachesmamstudent mnursemabout mhow mtomapplymthemnursingmprocessmwhenmprovidi
ngmpatient mcare.mWhichmstatement,mif mmadembymthemstudent mnurse,mindicatesmthat mteachingm
wasmsuccessful?
a. “Themnursingmprocessmismamscientific-
based mmethod mof mdiagnosingmthempatient’smhealthmcaremproblems.”
b. “Themnursingmprocessmismamproblem-solvingmtoolmused mtomidentifymand mtreat mpatients’
, healthmcaremneeds.”
c. “Themnursingmprocessmismused mprimarilymtomexplainmnursingminterventionsmtomoth
ermhealthmcaremprofessionals.”
d. “Themnursingmprocessmismbased monmnursingmtheorymthat mincorporatesmt
hembiopsychosocialmnaturemof mhumans.”
ANS:m B
Themnursingmprocessmismamproblem-
solvingmapproachmtomthemidentificationmand mtreatment mof mpatients’mproblems.mDiagnosismismonly
monemphasemof mthemnursingmprocess.mThemprimarymusemof mthemnursingmprocessmisminmpatient mcare,
mnot mtomestablishmnursingmtheorymormexplainmnursingminterventionsmtomothermhealthmcare mprofessi
onals.
DIF: CognitivemLevel:mUnderstand m(comprehension) REF:m 5
TOP:m NursingmProcess:mImplementation MSC:m NCLEX:mSafemand mEffective mCaremEnvironment
4. A mpatient mhasmbeenmadmitted mtomthemhospitalmformsurgerymand mtellsmthemnurse,m“I mdomnot mfeelmc
omfortablemleavingmmymchildrenmwithmmymparents.”mWhichmactionmshould mthemnursemtakemnext
?
a. Reassuremthempatient mthat mthesemfeelingsmaremcommonmformparents.
b. Havemthempatient mcallmthemchildrenmtomensuremthat mtheymaremdoingmwell.
c. Gathermmoremdatamabout mthempatient’smfeelingsmabout mthemchild-caremarrangements.
d. Callmthempatient’smparentsmtomdeterminemwhethermadequatemchild mcaremismbei
ngmprovided.
ANS:m C
Becausemamcompletemassessment mismnecessarym inmordermtomidentifymamproblemmand mchooseman ma
ppropriatemintervention,mthemnurse’smfirst mactionmshould mbemtomobtainmmoreminformation.m Themot
hermactionsmmaymbemappropriate,mbut mmoremassessment mismneeded mbeforemthembest minterventionmc
anmbemchosen.
DIF: CognitivemLevel:mApply m(application) REF: 6
OBJ:m SpecialmQuestions:mPrioritization
TOP:m NursingmProcess:mAssessmen
tmMSC:m NCLEX:mPsychosocialmIntegrity
5. A mpatient mwhomismparalyzed monmthemleft msidemof mthembodymaftermamstrokemdevelopsmampressuremul
cermonmthemleft mhip.mWhichmnursingmdiagnosismismmostmappropriate?
a. Impaired mphysicalmmobilitymrelated mtomleft-sided mparalysis
b. Riskmformimpaired mtissuemintegritymrelated mtomleft-sided mweakness
c. Impaired mskinmintegritymrelated mtomaltered mcirculationmand mpressure
d. Ineffectivemtissuemperfusionmrelated mtominabilitymtommovemindependently
ANS:m C
Thempatient’smmajormproblemmismthem impaired mskinmintegritymasmdemonstrated mbymthempresencem
of mampressuremulcer.mThemnursemismablemtomtreat mthemcausemof maltered mcirculationmand mpressure mb
ymfrequentlymrepositioningmthempatient.mAlthoughmleft-
sided mweaknessmismamproblemmformthempatient,mthemnursemcannot mtreat mthemweakness.mThem“riskmf
or”mdiagnosismismnot mappropriatemformthismpatient,mwhomalreadymhasmimpaired mtissuemintegrity.mT
hempatient mdoesmhavemineffectivemtissuemperfusion,mbut mthemimpaired mskinmintegritymdiagnosismi
ndicatesmmoremclearlymwhat mthemhealthmproblemmis.
DIF: CognitivemLevel:mApply m(application) REF: 7
TOP:m NursingmProcess:mDiagnosis MSC:m NCLEX:mPhysiologicalmIntegrity
, 6. A mpatient mwithmambacterialminfectionmhasmamnursingmdiagnosismof mdeficient mfluid mvolumemrelated
mtomexcessivemdiaphoresis.mWhichmoutcomemwould mthemnursemrecognizemasmappropriatemformthis
mpatient?
a. Patient mhasmambalanced mintakemand moutput.
b. Patient’smbeddingmismchanged mwhenmit mbecomesmdamp.
c. Patient munderstandsmthemneed mformincreased mfluid mintake.
d. Patient’smskinmremainsmcoolmand mdrymthroughout mhospitalization.
ANS:m A
Thismstatement mgivesmmeasurablemdatamshowingmresolutionmof mthemproblem mof mdeficient mfluid mv
olumemthat mwasmidentified minmthemnursingmdiagnosismstatement.mThemothermstatementsmwould mno
t mindicatemthat mthemproblemmof mdeficient mfluid mvolumemwasmresolved.
DIF: CognitivemLevel:mApply m(application) REF: 7
TOP:m NursingmProcess:mPlanning MSC:m NCLEX:mPhysiologicalmIntegrity
7. A mnursemasksmthempatient mif mpainmwasmrelieved maftermreceivingmmedication.mWhat mismthempurp
osemof mthemevaluationmphasemof mthemnursingmprocess?
a. Tomdeterminemif minterventionsmhavembeenmeffectiveminmmeetingmpatient moutcomes
b. Tomdocument mthemnursingmcaremplanminmthemprogressmnotesmof mthemmedicalmrecord
c. Tomdecidemwhethermthempatient’smhealthmproblemsmhavembeenmcompletelymresolved
d. Tomestablishmif mthempatient magreesmthat mthemnursingmcaremprovided mwasmsatisfactory
ANS:m A
Evaluationmconsistsmof mdeterminingmwhethermthemdesired mpatient moutcomesmhavembeenmmet ma
nd mwhethermthemnursingminterventionsmweremappropriate.m Themothermresponsesmdomnot mdescri
bemthemevaluationmphase.
DIF:m m CognitivemLevel:mUnderstand m(comprehension) REF:m 5
TOP:m NursingmProcess:mEvaluation MSC:m NCLEX:mSafemand mEffective mCaremEnvironment
8. Themnurseminterviewsmampatient mwhilemcompletingmthemhealthmhistorymand mphysicalmexaminatio
n.mWhat mismthempurposemof mthemassessment mphasemof mthemnursingmprocess?
a. Tomteachminterventionsmthat mrelievemhealthmproblems
b. Tomusempatient mdatamtomevaluatempatient mcaremoutcomes
c. Tomobtainmdatamwithmwhichmtomdiagnosempatient mproblems
d. Tomhelpmthempatient midentifymrealisticmoutcomesmformhealthmproblems
ANS:m C
Duringmthemassessment mphase,mthemnursemgathersminformationmabout mthempatient mtomdiagnosempat
ient mproblems.mThemothermresponsesmaremexamplesmof mthemplanning,m intervention,mand mevaluati
onmphasesmof mthemnursingmprocess.
DIF:m m CognitivemLevel:mUnderstand m(comprehension) REF:m 5
TOP:m NursingmProcess:mAssessment MSC:m NCLEX:mSafemand mEffective mCaremEnvironment
9. Whichmnursingmdiagnosismstatement mismwrittenmcorrectly?
a. Altered mtissuemperfusionmrelated mtomheart mfailure
b. Riskmformimpaired mtissuemintegritymrelated mtomsacralmredness
c. Ineffectivemcopingmrelated mtomresponsemtombiopsymtest mresults
d. Altered murinarymeliminationmrelated mtomurinarymtract minfection
m m m
Lewis Test-Bank.
m m
,Chapter m01:mProfessional mNursing mPractice mLe
wis:mMedical-SurgicalmNursing,m10thmEdition
MULTIPLEmCHOICE
1. Themnursemcompletesmanmadmissionmdatabasemand mexplainsmthat mthemplanmof mcaremand mdischarge
mgoalsmwillmbemdeveloped mwithmthempatient’sminput.mThempatient mstates,m“How mismthismdifferent mfr
ommwhat mthemdoctormdoes?”mWhichmresponsemwould mbemmostmappropriatemformthemnursemtomma
ke?
a. “Themrolemof mthemnursemismtomadministermmedicationsmand mothermtreatmentsmprescrib
ed mbymyourmdoctor.”
b. “Themnurse’smjobmismtomhelpmthemdoctormbymcollectingminformationma
nd mcommunicatingmanymproblemsmthat moccur.”
c. “Nursesmperformmmanymof mthemsamemproceduresmasmthemdoctor,mbut mnursesmaremwi
thmthempatientsmformamlongermtimemthanmthemdoctor.”
d. “Inmadditionmtomcaringmformyoumwhilemyoumaremsick,mthemnursesmwillmassist myou
mtomdevelopmanmindividualized mplanmtommaintainmyourmhealth.”
ANS:m D
Thismresponsemismconsistent mwithmthemAmericanmNursesmAssociationm(ANA)mdefinitionmof mnursi
ng,mwhichmdescribesmthemrolemof mnursesminmpromotingmhealth.mThemothermresponsesmdescribemso
memof mthemdependent mand mcollaborativemfunctionsmof mthemnursingmrolembut mdomnot maccuratelymd
escribemthemnurse’smroleminmthemhealthmcarem system.
DIF: CognitivemLevel:mUnderstand m(comprehension) REF:m 3
TOP:m NursingmProcess:mImplementation MSC:m NCLEX:mSafemand mEffective mCaremEnvironment
2. Themnursemdescribesmtomamstudent mnursemhow mtomusemevidence-
based mpracticemguidelinesmwhenmcaringmformpatients.mWhichmstatement,mif mmadembymthemnur
se,mwould mbemthemmostmaccurate?
a. “Inferencesmfrommclinicalmresearchmstudiesmaremused masmamguide.”
b. “Patient mcaremismbased monmclinicalmjudgment,mexperience,mand mtraditions.”
c. “Datamaremevaluated mtomshow mthat mthempatient moutcomesmaremconsistentlymmet.”
d. “Recommendationsmarembased monmresearch,mclinicalmexpertise,mand mpatie
nt mpreferences.”
ANS:m D
Evidence-based mpracticem(EBP)mismthemusemof mthembest mresearch-
based mevidencemcombined mwithmclinicianmexpertise.mClinicalmjudgment mbased monmthemnurse’smcl
inicalmexperiencemismpart mof mEBP,mbut mclinicalmdecisionmmakingm should malsom incorporatemcurren
t mresearchmand mresearch-
based mguidelines.mEvaluationmof mpatient moutcomesmismimportant,mbut minterventionsmshould mbemb
ased monmresearchmfrommrandomized mcontrolmstudiesmwithmamlargemnumbermof msubjects.
DIF: CognitivemLevel:mRememberm(knowledge) REF:m 15
TOP:m NursingmProcess:mPlanning MSC:m NCLEX:mSafemand mEffective mCaremEnvironment
3. Themnursemteachesmamstudent mnursemabout mhow mtomapplymthemnursingmprocessmwhenmprovidi
ngmpatient mcare.mWhichmstatement,mif mmadembymthemstudent mnurse,mindicatesmthat mteachingm
wasmsuccessful?
a. “Themnursingmprocessmismamscientific-
based mmethod mof mdiagnosingmthempatient’smhealthmcaremproblems.”
b. “Themnursingmprocessmismamproblem-solvingmtoolmused mtomidentifymand mtreat mpatients’
, healthmcaremneeds.”
c. “Themnursingmprocessmismused mprimarilymtomexplainmnursingminterventionsmtomoth
ermhealthmcaremprofessionals.”
d. “Themnursingmprocessmismbased monmnursingmtheorymthat mincorporatesmt
hembiopsychosocialmnaturemof mhumans.”
ANS:m B
Themnursingmprocessmismamproblem-
solvingmapproachmtomthemidentificationmand mtreatment mof mpatients’mproblems.mDiagnosismismonly
monemphasemof mthemnursingmprocess.mThemprimarymusemof mthemnursingmprocessmisminmpatient mcare,
mnot mtomestablishmnursingmtheorymormexplainmnursingminterventionsmtomothermhealthmcare mprofessi
onals.
DIF: CognitivemLevel:mUnderstand m(comprehension) REF:m 5
TOP:m NursingmProcess:mImplementation MSC:m NCLEX:mSafemand mEffective mCaremEnvironment
4. A mpatient mhasmbeenmadmitted mtomthemhospitalmformsurgerymand mtellsmthemnurse,m“I mdomnot mfeelmc
omfortablemleavingmmymchildrenmwithmmymparents.”mWhichmactionmshould mthemnursemtakemnext
?
a. Reassuremthempatient mthat mthesemfeelingsmaremcommonmformparents.
b. Havemthempatient mcallmthemchildrenmtomensuremthat mtheymaremdoingmwell.
c. Gathermmoremdatamabout mthempatient’smfeelingsmabout mthemchild-caremarrangements.
d. Callmthempatient’smparentsmtomdeterminemwhethermadequatemchild mcaremismbei
ngmprovided.
ANS:m C
Becausemamcompletemassessment mismnecessarym inmordermtomidentifymamproblemmand mchooseman ma
ppropriatemintervention,mthemnurse’smfirst mactionmshould mbemtomobtainmmoreminformation.m Themot
hermactionsmmaymbemappropriate,mbut mmoremassessment mismneeded mbeforemthembest minterventionmc
anmbemchosen.
DIF: CognitivemLevel:mApply m(application) REF: 6
OBJ:m SpecialmQuestions:mPrioritization
TOP:m NursingmProcess:mAssessmen
tmMSC:m NCLEX:mPsychosocialmIntegrity
5. A mpatient mwhomismparalyzed monmthemleft msidemof mthembodymaftermamstrokemdevelopsmampressuremul
cermonmthemleft mhip.mWhichmnursingmdiagnosismismmostmappropriate?
a. Impaired mphysicalmmobilitymrelated mtomleft-sided mparalysis
b. Riskmformimpaired mtissuemintegritymrelated mtomleft-sided mweakness
c. Impaired mskinmintegritymrelated mtomaltered mcirculationmand mpressure
d. Ineffectivemtissuemperfusionmrelated mtominabilitymtommovemindependently
ANS:m C
Thempatient’smmajormproblemmismthem impaired mskinmintegritymasmdemonstrated mbymthempresencem
of mampressuremulcer.mThemnursemismablemtomtreat mthemcausemof maltered mcirculationmand mpressure mb
ymfrequentlymrepositioningmthempatient.mAlthoughmleft-
sided mweaknessmismamproblemmformthempatient,mthemnursemcannot mtreat mthemweakness.mThem“riskmf
or”mdiagnosismismnot mappropriatemformthismpatient,mwhomalreadymhasmimpaired mtissuemintegrity.mT
hempatient mdoesmhavemineffectivemtissuemperfusion,mbut mthemimpaired mskinmintegritymdiagnosismi
ndicatesmmoremclearlymwhat mthemhealthmproblemmis.
DIF: CognitivemLevel:mApply m(application) REF: 7
TOP:m NursingmProcess:mDiagnosis MSC:m NCLEX:mPhysiologicalmIntegrity
, 6. A mpatient mwithmambacterialminfectionmhasmamnursingmdiagnosismof mdeficient mfluid mvolumemrelated
mtomexcessivemdiaphoresis.mWhichmoutcomemwould mthemnursemrecognizemasmappropriatemformthis
mpatient?
a. Patient mhasmambalanced mintakemand moutput.
b. Patient’smbeddingmismchanged mwhenmit mbecomesmdamp.
c. Patient munderstandsmthemneed mformincreased mfluid mintake.
d. Patient’smskinmremainsmcoolmand mdrymthroughout mhospitalization.
ANS:m A
Thismstatement mgivesmmeasurablemdatamshowingmresolutionmof mthemproblem mof mdeficient mfluid mv
olumemthat mwasmidentified minmthemnursingmdiagnosismstatement.mThemothermstatementsmwould mno
t mindicatemthat mthemproblemmof mdeficient mfluid mvolumemwasmresolved.
DIF: CognitivemLevel:mApply m(application) REF: 7
TOP:m NursingmProcess:mPlanning MSC:m NCLEX:mPhysiologicalmIntegrity
7. A mnursemasksmthempatient mif mpainmwasmrelieved maftermreceivingmmedication.mWhat mismthempurp
osemof mthemevaluationmphasemof mthemnursingmprocess?
a. Tomdeterminemif minterventionsmhavembeenmeffectiveminmmeetingmpatient moutcomes
b. Tomdocument mthemnursingmcaremplanminmthemprogressmnotesmof mthemmedicalmrecord
c. Tomdecidemwhethermthempatient’smhealthmproblemsmhavembeenmcompletelymresolved
d. Tomestablishmif mthempatient magreesmthat mthemnursingmcaremprovided mwasmsatisfactory
ANS:m A
Evaluationmconsistsmof mdeterminingmwhethermthemdesired mpatient moutcomesmhavembeenmmet ma
nd mwhethermthemnursingminterventionsmweremappropriate.m Themothermresponsesmdomnot mdescri
bemthemevaluationmphase.
DIF:m m CognitivemLevel:mUnderstand m(comprehension) REF:m 5
TOP:m NursingmProcess:mEvaluation MSC:m NCLEX:mSafemand mEffective mCaremEnvironment
8. Themnurseminterviewsmampatient mwhilemcompletingmthemhealthmhistorymand mphysicalmexaminatio
n.mWhat mismthempurposemof mthemassessment mphasemof mthemnursingmprocess?
a. Tomteachminterventionsmthat mrelievemhealthmproblems
b. Tomusempatient mdatamtomevaluatempatient mcaremoutcomes
c. Tomobtainmdatamwithmwhichmtomdiagnosempatient mproblems
d. Tomhelpmthempatient midentifymrealisticmoutcomesmformhealthmproblems
ANS:m C
Duringmthemassessment mphase,mthemnursemgathersminformationmabout mthempatient mtomdiagnosempat
ient mproblems.mThemothermresponsesmaremexamplesmof mthemplanning,m intervention,mand mevaluati
onmphasesmof mthemnursingmprocess.
DIF:m m CognitivemLevel:mUnderstand m(comprehension) REF:m 5
TOP:m NursingmProcess:mAssessment MSC:m NCLEX:mSafemand mEffective mCaremEnvironment
9. Whichmnursingmdiagnosismstatement mismwrittenmcorrectly?
a. Altered mtissuemperfusionmrelated mtomheart mfailure
b. Riskmformimpaired mtissuemintegritymrelated mtomsacralmredness
c. Ineffectivemcopingmrelated mtomresponsemtombiopsymtest mresults
d. Altered murinarymeliminationmrelated mtomurinarymtract minfection
