[[
NURSINGTB.COM
,Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada
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Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
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MULTIPLE CHOICE fff
1. When caring for clients using evidence-informed practice, which of the following does
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the nurse use?
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a. Clinical judgement based on experience fff fff fff fff
b. Evidence from a clinical research study fff fff fff fff fff
c. The best available evidence to guide clinical expertise
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d. Evaluation of data showing that the client outcomes are met fff fff fff fff fff fff fff fff fff
ANS: f f f C
Evidence-informed nursing practice is a continuous interactive process involving the fff fff fff fff fff fff fff fff fff
explicit, conscientious, and judicious consideration of the best available evidence to
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provide care. Four primary elements are: (a) clinical state, setting, and circumstances;
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(b) client preferences and actions; (c) best research evidence; and (d) health care
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resources. Clinical judgement based on the nurse’s clinical experience is part of EIP, but
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clinical decision making also should incorporate current research and research-based
fff fff fff fff fff fff fff fff fff fff
guidelines. Evidence from one clinical research study does not provide an adequate
fff fff fff fff fff fff fff fff fff fff fff fff
substantiation for interventions. Evaluation of client outcomes is important, but
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interventions should be based on research from randomized control studies with a large
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number of subjects.
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DIF: Cognitive Level: Comprehension fff fff TOP: f f f Nursing Process: Planning fff fff
2. Which of the following best N
e x p lRa i n sIt h eGn u B
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e sC imary use of the nursing process when
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providing care to USNT O fff fff fff fff fff
clients?
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a. To explain nursing interventions to other health care professionals
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b. As a problem-solving tool to identify and treat clients’ health care needs
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c. As a scientific-based process of diagnosing the client’s health care problems
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d. To establish nursing theory that incorporates the biopsychosocial nature of humans
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ANS: f f f B
The nursing process is an assertive problem-solving approach to the identification and
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treatment of clients’ problems. Diagnosis is only one phase of the nursing process. The
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primary use of the nursing process is in client care, not to establish nursing theory or
fff fff fff fff fff fff fff fff fff fff fff fff fff fff fff fff
explain nursing interventions to other health care professionals.
fff fff fff fff fff fff fff fff
DIF: Cognitive Level: Comprehension fff fff TOP: f f f Nursing Process: Implementation fff fff
3. The nurse is caring for a critically ill client in the intensive care unit and plans an every
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2-hour turning schedule to prevent skin breakdown. Which type of nursing function is
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demonstrated with this turning schedule?
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a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: f f f D
NURSINGTB.COM
, When implementing collaborative nursing actions, the nurse is responsible primarily for
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monitoring for complications of acute illness or providing care to prevent or treat
fff fff fff fff fff fff fff fff fff fff fff fff fff
complications. Independent nursing actions are focused on health promotion, illness
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prevention, and client advocacy. A dependent action would require a physician order to
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implement. Cooperative nursing functions are not described as one of the formal nursing
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functions.
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DIF: Cognitive Level: Application fff fff TOP: f f f Nursing Process: Implementation fff fff
4. The nurse is caring for a client who has been admitted to the hospital for surgery and
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tells the nurse, “I do not feel right about leaving my children with my neighbour.”
fff fff fff fff fff fff fff fff fff fff fff fff fff fff fff
Which action should the nurse take next?
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a. Reassure the client that these feelings are common for parents. fff fff fff fff fff fff fff fff fff
b. Have the client call the children to ensure that they are doing well.
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c. Call the neighbour to determine whether adequate childcare is being provided.
fff fff fff fff fff fff fff fff fff fff
d. Gather more data about the client’s feelings about the childcare arrangements.
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ANS: f f f D
Since a complete assessment is necessary in order to identify a problem and choose an
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appropriate intervention, the nurse’s first action should be to obtain more information.
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The other actions may be appropriate, but more assessment is needed before the best
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intervention can be chosen.
fff fff fff fff
DIF: Cognitive Level: Application fff fff TOP: f f f Nursing Process: Assessment fff fff
5. The nurse is caring for a client who has left-sided paralysis as the result of a stroke and
fff fff fff fff fff fff fff fff fff fff fff fff fff fff fff fff fff
assesses a pressure injury on the clie nt’s left h ip . W hich of the following is the most
appropriate nursing diagnosisNfUo R hI Gl i e B
nTt.
?C M
fff fff fff ff f fff fff fff fff fff fff fff
r tS i s cN fff O fff fff fff fff
a. Impaired physical mobility related to decrease in muscle control (left-
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sided paralysis) fff
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge
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about protecting tissue integrity
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c. Impaired skin integrity related to pressure over bony prominence fff fff fff fff fff fff fff fff
(impaired circulation)
fff fff
d. Ineffective tissue perfusion related to sedentary lifestyle fff fff fff fff fff fff
ANS: f f f C
The client’s major problem is the impaired skin integrity as demonstrated by the presence
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of a pressure injury. The nurse is able to treat the cause of altered circulation and
fff fff fff fff fff fff fff fff fff fff fff fff fff fff fff fff
pressure by frequently repositioning the client. Although left-sided weakness is a
fff fff fff fff fff fff fff fff fff fff fff
problem for the client,
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the nurse cannot treat the weakness. The “risk for” diagnosis is not appropriate for this
fff fff fff fff fff fff fff fff fff fff fff fff fff fff
client, who already has impaired tissue integrity. The client does have ineffective tissue
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perfusion, but the impaired skin integrity diagnosis indicates more clearly what the
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health problem is.
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DIF: Cognitive Level: Application fff fff TOP: f f f Nursing Process: Diagnosis fff fff
6. The nurse caring for a client with an infection has a nursing diagnosis of deficient
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fluid volume related to excessive diaphoresis. Which of the following is an
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appropriate client outcome?
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a. Client has a balanced intake and output. fff fff fff fff fff fff
b. Client’s bedding is changed when it becomes damp. fff fff fff fff fff fff fff
NURSINGTB.COM
, c. Client understands the need for increased fluid intake.
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d. Client’s skin remains cool and dry throughout hospitalization.
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ANS: f f f A
This statement gives measurable data showing resolution of the problem of deficient
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fluid volume that was identified in the nursing diagnosis statement. The other statements
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would not indicate that the problem of deficient fluid volume was resolved.
fff fff fff fff fff fff fff fff fff fff fff fff
DIF: Cognitive Level: Application fff fff TOP: f f f Nursing Process: Planning fff fff
7. Which of the following represents a nursing activity that is carried out during the
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evaluation phase of the nursing process?
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a. Determining if interventions have been effective in meeting client outcomes fff fff fff fff fff fff fff fff fff
b. Documenting the nursing care plan in the progress notes in the medical record fff fff fff fff fff fff fff fff fff fff fff fff
c. Deciding whether the client’s health problems have been completely resolved
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d. Asking the client to evaluate whether the nursing care provided was satisfactory
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ANS: f f f A
Evaluation consists of determining whether the desired client outcomes have been met
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and whether the nursing interventions were appropriate. The other responses do not
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describe the evaluation phase.
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DIF: Cognitive Level: Comprehension fff fff TOP: f f f Nursing Process: Evaluation fff fff
8. Which of the following would the nurse perform during the assessment phase of the
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nursing process?
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a. Obtains data with which to diagnose client problems
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b. Uses client data to develoNp pR
fff
US NItTy nGursB
riori in.
gOC
d iagMnoses
c. Teaches interventions to relieve client health problems
fff
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fff fff
fff
fff fff
fff
fff
fff
fff
fff
fff
d. Assists the client to identify realistic outcomes to health problems
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ANS: f f f A
During the assessment phase, the nurse gathers information about the client. The other
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responses are examples of the intervention, diagnosis, and planning phases of the nursing
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process.
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DIF: Cognitive Level: Knowledge fff fff TOP: f f f Nursing Process: Assessment fff fff
9. Which of the following is an example of a correctly written nursing diagnosis statement?
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a. Altered tissue perfusion related to heart failure
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b. Risk for impaired tissue integrity related to sacral redness
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c. Ineffective coping related to insufficient sense of control. fff fff fff fff fff fff fff
d. Altered urinary elimination related to urinary tract infection
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ANS: f f f C
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that
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describes a client’s response to a health problem that can be treated by nursing. The
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use of a medical diagnosis (as in the responses beginning “Altered tissue perfusion”
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and “Altered urinary
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elimination”) is not appropriate. The response beginning “Risk for impaired tissue integrity”
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uses the defining characteristics as the etiology.
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DIF: Cognitive Level: Comprehension fff fff TOP: f f f Nursing Process: Diagnosis fff fff
NURSINGTB.COM
NURSINGTB.COM
,Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada
fff fff fff fff fff fff fff fff
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
fff fff fff fff fff fff fff fff
MULTIPLE CHOICE fff
1. When caring for clients using evidence-informed practice, which of the following does
fff fff fff fff fff fff fff fff fff fff fff
the nurse use?
fff fff fff
a. Clinical judgement based on experience fff fff fff fff
b. Evidence from a clinical research study fff fff fff fff fff
c. The best available evidence to guide clinical expertise
fff fff fff fff fff fff fff
d. Evaluation of data showing that the client outcomes are met fff fff fff fff fff fff fff fff fff
ANS: f f f C
Evidence-informed nursing practice is a continuous interactive process involving the fff fff fff fff fff fff fff fff fff
explicit, conscientious, and judicious consideration of the best available evidence to
fff fff fff fff fff fff fff fff fff fff fff
provide care. Four primary elements are: (a) clinical state, setting, and circumstances;
fff fff fff fff fff fff fff fff fff fff fff fff
(b) client preferences and actions; (c) best research evidence; and (d) health care
fff fff fff fff fff fff fff fff fff fff fff fff fff
resources. Clinical judgement based on the nurse’s clinical experience is part of EIP, but
fff fff fff fff fff fff fff fff fff fff fff fff fff fff
clinical decision making also should incorporate current research and research-based
fff fff fff fff fff fff fff fff fff fff
guidelines. Evidence from one clinical research study does not provide an adequate
fff fff fff fff fff fff fff fff fff fff fff fff
substantiation for interventions. Evaluation of client outcomes is important, but
fff fff fff fff fff fff fff fff fff fff
interventions should be based on research from randomized control studies with a large
fff fff fff fff fff fff fff fff fff fff fff fff fff
number of subjects.
fff fff fff
DIF: Cognitive Level: Comprehension fff fff TOP: f f f Nursing Process: Planning fff fff
2. Which of the following best N
e x p lRa i n sIt h eGn u B
ff f fff r s. ’ prM
e sC imary use of the nursing process when
fff fff fff fff fff ff f fff fff fff fff
providing care to USNT O fff fff fff fff fff
clients?
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a. To explain nursing interventions to other health care professionals
fff fff fff fff fff fff fff fff
b. As a problem-solving tool to identify and treat clients’ health care needs
fff fff fff fff fff fff fff fff fff fff fff
c. As a scientific-based process of diagnosing the client’s health care problems
fff fff fff fff fff fff fff fff fff fff
d. To establish nursing theory that incorporates the biopsychosocial nature of humans
fff fff fff fff fff fff fff fff fff fff
ANS: f f f B
The nursing process is an assertive problem-solving approach to the identification and
fff fff fff fff fff fff fff fff fff fff fff
treatment of clients’ problems. Diagnosis is only one phase of the nursing process. The
fff fff fff fff fff fff fff fff fff fff fff fff fff
primary use of the nursing process is in client care, not to establish nursing theory or
fff fff fff fff fff fff fff fff fff fff fff fff fff fff fff fff
explain nursing interventions to other health care professionals.
fff fff fff fff fff fff fff fff
DIF: Cognitive Level: Comprehension fff fff TOP: f f f Nursing Process: Implementation fff fff
3. The nurse is caring for a critically ill client in the intensive care unit and plans an every
fff fff fff fff fff fff fff fff fff fff fff fff fff fff fff fff fff
2-hour turning schedule to prevent skin breakdown. Which type of nursing function is
fff fff fff fff fff fff fff fff fff fff fff fff fff
demonstrated with this turning schedule?
fff fff fff fff fff
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: f f f D
NURSINGTB.COM
, When implementing collaborative nursing actions, the nurse is responsible primarily for
fff fff fff fff fff fff fff fff fff fff
monitoring for complications of acute illness or providing care to prevent or treat
fff fff fff fff fff fff fff fff fff fff fff fff fff
complications. Independent nursing actions are focused on health promotion, illness
fff fff fff fff fff fff fff fff fff fff
prevention, and client advocacy. A dependent action would require a physician order to
fff fff fff fff fff fff fff fff fff fff fff fff fff
implement. Cooperative nursing functions are not described as one of the formal nursing
fff fff fff fff fff fff fff fff fff fff fff fff fff
functions.
fff
DIF: Cognitive Level: Application fff fff TOP: f f f Nursing Process: Implementation fff fff
4. The nurse is caring for a client who has been admitted to the hospital for surgery and
fff fff fff fff fff fff fff fff fff fff fff fff fff fff fff fff
tells the nurse, “I do not feel right about leaving my children with my neighbour.”
fff fff fff fff fff fff fff fff fff fff fff fff fff fff fff
Which action should the nurse take next?
fff fff fff fff fff fff fff
a. Reassure the client that these feelings are common for parents. fff fff fff fff fff fff fff fff fff
b. Have the client call the children to ensure that they are doing well.
fff fff fff fff fff fff fff fff fff fff fff fff
c. Call the neighbour to determine whether adequate childcare is being provided.
fff fff fff fff fff fff fff fff fff fff
d. Gather more data about the client’s feelings about the childcare arrangements.
fff fff fff fff fff fff fff fff fff fff
ANS: f f f D
Since a complete assessment is necessary in order to identify a problem and choose an
fff fff fff fff fff fff fff fff fff fff fff fff fff fff
appropriate intervention, the nurse’s first action should be to obtain more information.
fff fff fff fff fff fff fff fff fff fff fff fff
The other actions may be appropriate, but more assessment is needed before the best
fff fff fff fff fff fff fff fff fff fff fff fff fff fff
intervention can be chosen.
fff fff fff fff
DIF: Cognitive Level: Application fff fff TOP: f f f Nursing Process: Assessment fff fff
5. The nurse is caring for a client who has left-sided paralysis as the result of a stroke and
fff fff fff fff fff fff fff fff fff fff fff fff fff fff fff fff fff
assesses a pressure injury on the clie nt’s left h ip . W hich of the following is the most
appropriate nursing diagnosisNfUo R hI Gl i e B
nTt.
?C M
fff fff fff ff f fff fff fff fff fff fff fff
r tS i s cN fff O fff fff fff fff
a. Impaired physical mobility related to decrease in muscle control (left-
fff fff fff fff fff fff fff fff fff
sided paralysis) fff
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge
fff fff fff fff fff fff fff fff fff
about protecting tissue integrity
fff fff fff fff
c. Impaired skin integrity related to pressure over bony prominence fff fff fff fff fff fff fff fff
(impaired circulation)
fff fff
d. Ineffective tissue perfusion related to sedentary lifestyle fff fff fff fff fff fff
ANS: f f f C
The client’s major problem is the impaired skin integrity as demonstrated by the presence
fff fff fff fff fff fff fff fff fff fff fff fff fff
of a pressure injury. The nurse is able to treat the cause of altered circulation and
fff fff fff fff fff fff fff fff fff fff fff fff fff fff fff fff
pressure by frequently repositioning the client. Although left-sided weakness is a
fff fff fff fff fff fff fff fff fff fff fff
problem for the client,
fff fff fff fff
the nurse cannot treat the weakness. The “risk for” diagnosis is not appropriate for this
fff fff fff fff fff fff fff fff fff fff fff fff fff fff
client, who already has impaired tissue integrity. The client does have ineffective tissue
fff fff fff fff fff fff fff fff fff fff fff fff fff
perfusion, but the impaired skin integrity diagnosis indicates more clearly what the
fff fff fff fff fff fff fff fff fff fff fff fff
health problem is.
fff fff fff
DIF: Cognitive Level: Application fff fff TOP: f f f Nursing Process: Diagnosis fff fff
6. The nurse caring for a client with an infection has a nursing diagnosis of deficient
fff fff fff fff fff fff fff fff fff fff fff fff fff fff
fluid volume related to excessive diaphoresis. Which of the following is an
fff fff fff fff fff fff fff fff fff fff fff fff
appropriate client outcome?
fff fff fff
a. Client has a balanced intake and output. fff fff fff fff fff fff
b. Client’s bedding is changed when it becomes damp. fff fff fff fff fff fff fff
NURSINGTB.COM
, c. Client understands the need for increased fluid intake.
fff fff fff fff fff fff fff
d. Client’s skin remains cool and dry throughout hospitalization.
fff fff fff fff fff fff fff
ANS: f f f A
This statement gives measurable data showing resolution of the problem of deficient
fff fff fff fff fff fff fff fff fff fff fff
fluid volume that was identified in the nursing diagnosis statement. The other statements
fff fff fff fff fff fff fff fff fff fff fff fff fff
would not indicate that the problem of deficient fluid volume was resolved.
fff fff fff fff fff fff fff fff fff fff fff fff
DIF: Cognitive Level: Application fff fff TOP: f f f Nursing Process: Planning fff fff
7. Which of the following represents a nursing activity that is carried out during the
fff fff fff fff fff fff fff fff fff fff fff fff fff
evaluation phase of the nursing process?
fff fff fff fff fff fff
a. Determining if interventions have been effective in meeting client outcomes fff fff fff fff fff fff fff fff fff
b. Documenting the nursing care plan in the progress notes in the medical record fff fff fff fff fff fff fff fff fff fff fff fff
c. Deciding whether the client’s health problems have been completely resolved
fff fff fff fff fff fff fff fff fff
d. Asking the client to evaluate whether the nursing care provided was satisfactory
fff fff fff fff fff fff fff fff fff fff fff
ANS: f f f A
Evaluation consists of determining whether the desired client outcomes have been met
fff fff fff fff fff fff fff fff fff fff fff
and whether the nursing interventions were appropriate. The other responses do not
fff fff fff fff fff fff fff fff fff fff fff fff
describe the evaluation phase.
fff fff fff fff
DIF: Cognitive Level: Comprehension fff fff TOP: f f f Nursing Process: Evaluation fff fff
8. Which of the following would the nurse perform during the assessment phase of the
fff fff fff fff fff fff fff fff fff fff fff fff fff
nursing process?
fff fff
a. Obtains data with which to diagnose client problems
fff fff fff fff fff fff fff
b. Uses client data to develoNp pR
fff
US NItTy nGursB
riori in.
gOC
d iagMnoses
c. Teaches interventions to relieve client health problems
fff
fff fff fff
fff fff
fff
fff fff
fff
fff
fff
fff
fff
fff
d. Assists the client to identify realistic outcomes to health problems
fff fff fff fff fff fff fff fff fff
ANS: f f f A
During the assessment phase, the nurse gathers information about the client. The other
fff fff fff fff fff fff fff fff fff fff fff fff
responses are examples of the intervention, diagnosis, and planning phases of the nursing
fff fff fff fff fff fff fff fff fff fff fff fff fff
process.
fff
DIF: Cognitive Level: Knowledge fff fff TOP: f f f Nursing Process: Assessment fff fff
9. Which of the following is an example of a correctly written nursing diagnosis statement?
fff fff fff fff fff fff fff fff fff fff fff fff fff
a. Altered tissue perfusion related to heart failure
fff fff fff fff fff fff
b. Risk for impaired tissue integrity related to sacral redness
fff fff fff fff fff fff fff fff
c. Ineffective coping related to insufficient sense of control. fff fff fff fff fff fff fff
d. Altered urinary elimination related to urinary tract infection
fff fff fff fff fff fff fff
ANS: f f f C
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that
fff fff fff fff fff fff fff fff fff fff fff
describes a client’s response to a health problem that can be treated by nursing. The
fff fff fff fff fff fff fff fff fff fff fff fff fff fff fff
use of a medical diagnosis (as in the responses beginning “Altered tissue perfusion”
fff fff fff fff fff fff fff fff fff fff fff fff fff
and “Altered urinary
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elimination”) is not appropriate. The response beginning “Risk for impaired tissue integrity”
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uses the defining characteristics as the etiology.
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DIF: Cognitive Level: Comprehension fff fff TOP: f f f Nursing Process: Diagnosis fff fff
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