Lewis's Medical-Surgical Nursing: Assessment
and Management of Clinical Problems 11th Edition
TESTBANK
Table of Contents
Chapter 1. Professional Nursing
MULTIPLE CHOICE
1. The nurse completes an admission database and explains that the plan of care and
discharge goals will be developed with the patients input. The patient states, How is
this different from what the doctor does? Which response would be most appropriate
for the nurse to make?
a. The role of the nurse is to administer medications and other treatments
prescribed by your doctor.
b. The nurses job is to help the doctor by collecting information and
communicating any problems that occur.
c. Nurses perform many of the same procedures as the doctor, but nurses
are with the patients for a longer time than the doctor.
d. In addition to caring for you while you are sick, the nurses will assist
you to develop an individualized plan to maintain your health.
ANS: D
This response is consistent with the American Nurses Association (ANA) definition
of nursing, which describes the role of nurses in promoting health. The other
responses describe some of the dependent and collaborative functions of the nursing
role but do not accurately describe the nurses role in the health care system.
DIF: Cognitive Level: Understand (comprehension) REF: 3
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
,2. The nurse describes to a student nurse how to use evidence-based practice
guidelines when caring for patients. Which statement, if made by the nurse, would be
the most accurate?
a. Inferences from clinical research studies are used as a guide.
b. Patient care is based on clinical judgment, experience, and traditions.
c. Data are evaluated to show that the patient outcomes are consistently
met.
d. Recommendations are based on research, clinical expertise, and patient
preferences.
ANS: D
Evidence-based practice (EBP) is the use of the best research-based evidence
combined with clinician expertise. Clinical judgment based on the nurses clinical
experience is part of EBP, but clinical decision making should also incorporate
current research and research-based guidelines. Evaluation of patient outcomes is
important, but interventions should be based on research from randomized control
studies with a large number of subjects.
DIF: Cognitive Level: Remember (knowledge) REF: 11
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
3. The nurse teaches a student nurse about how to apply the nursing process when
providing patient care. Which statement, if made by the student nurse, indicates that
teaching was successful?
a. The nursing process is a scientific-based method of diagnosing the
patients health care problems.
b. The nursing process is a problem-solving tool used to identify and treat
patients health care needs.
c. The nursing process is based on nursing theory that incorporates the
biopsychosocial nature of humans.
,d. The nursing process is used primarily to explain nursing interventions to
other health care professionals.
ANS: B
The nursing process is a problem-solving approach to the identification and treatment
of patients problems. Diagnosis is only one phase of the nursing process. The primary
use of the nursing process is in patient care, not to establish nursing theory or explain
nursing interventions to other health care professionals.
DIF: Cognitive Level: Understand (comprehension) REF: 7
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
4. A patient has been admitted to the hospital for surgery and tells the nurse, I do not
feel comfortable leaving my children with my parents. Which action should the nurse
take next?
a. Reassure the patient that these feelings are common for parents.
b. Have the patient call the children to ensure that they are doing well.
c. Gather more data about the patients feelings about the child-care
arrangements.
d. Call the patients parents to determine whether adequate child care is
being provided.
ANS: C
Since a complete assessment is necessary in order to identify a problem and choose an
appropriate intervention, the nurses first action should be to obtain more information.
The other actions may be appropriate, but more assessment is needed before the best
intervention can be chosen.
DIF: Cognitive Level: Apply (application) REF: 6-7
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
, MSC: NCLEX: Psychosocial Integrity
5. A patient who is paralyzed on the left side of the body after a stroke develops a
pressure ulcer on the left hip. Which nursing diagnosis is most appropriate?
a. Impaired physical mobility related to left-sided paralysis
b. Risk for impaired tissue integrity related to left-sided weakness
c. Impaired skin integrity related to altered circulation and pressure
d. Ineffective tissue perfusion related to inability to move independently
ANS: C
The patients major problem is the impaired skin integrity as demonstrated by the
presence of a pressure ulcer. The nurse is able to treat the cause of altered circulation
and pressure by frequently repositioning the patient. Although left-sided weakness is a
problem for the patient, the nurse cannot treat the weakness. The risk for diagnosis is
not appropriate for this patient, who already has impaired tissue integrity. The patient
does have ineffective tissue perfusion, but the impaired skin integrity diagnosis
indicates more clearly what the health problem is.
DIF: Cognitive Level: Apply (application) REF: 7-9
TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity
6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume
related to excessive diaphoresis. Which outcome would the nurse recognize as most
appropriate for this patient?
a. Patient has a balanced intake and output.
b. Patients bedding is changed when it becomes damp.
c. Patient understands the need for increased fluid intake.
d. Patients skin remains cool and dry throughout hospitalization.
ANS: A
and Management of Clinical Problems 11th Edition
TESTBANK
Table of Contents
Chapter 1. Professional Nursing
MULTIPLE CHOICE
1. The nurse completes an admission database and explains that the plan of care and
discharge goals will be developed with the patients input. The patient states, How is
this different from what the doctor does? Which response would be most appropriate
for the nurse to make?
a. The role of the nurse is to administer medications and other treatments
prescribed by your doctor.
b. The nurses job is to help the doctor by collecting information and
communicating any problems that occur.
c. Nurses perform many of the same procedures as the doctor, but nurses
are with the patients for a longer time than the doctor.
d. In addition to caring for you while you are sick, the nurses will assist
you to develop an individualized plan to maintain your health.
ANS: D
This response is consistent with the American Nurses Association (ANA) definition
of nursing, which describes the role of nurses in promoting health. The other
responses describe some of the dependent and collaborative functions of the nursing
role but do not accurately describe the nurses role in the health care system.
DIF: Cognitive Level: Understand (comprehension) REF: 3
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
,2. The nurse describes to a student nurse how to use evidence-based practice
guidelines when caring for patients. Which statement, if made by the nurse, would be
the most accurate?
a. Inferences from clinical research studies are used as a guide.
b. Patient care is based on clinical judgment, experience, and traditions.
c. Data are evaluated to show that the patient outcomes are consistently
met.
d. Recommendations are based on research, clinical expertise, and patient
preferences.
ANS: D
Evidence-based practice (EBP) is the use of the best research-based evidence
combined with clinician expertise. Clinical judgment based on the nurses clinical
experience is part of EBP, but clinical decision making should also incorporate
current research and research-based guidelines. Evaluation of patient outcomes is
important, but interventions should be based on research from randomized control
studies with a large number of subjects.
DIF: Cognitive Level: Remember (knowledge) REF: 11
TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment
3. The nurse teaches a student nurse about how to apply the nursing process when
providing patient care. Which statement, if made by the student nurse, indicates that
teaching was successful?
a. The nursing process is a scientific-based method of diagnosing the
patients health care problems.
b. The nursing process is a problem-solving tool used to identify and treat
patients health care needs.
c. The nursing process is based on nursing theory that incorporates the
biopsychosocial nature of humans.
,d. The nursing process is used primarily to explain nursing interventions to
other health care professionals.
ANS: B
The nursing process is a problem-solving approach to the identification and treatment
of patients problems. Diagnosis is only one phase of the nursing process. The primary
use of the nursing process is in patient care, not to establish nursing theory or explain
nursing interventions to other health care professionals.
DIF: Cognitive Level: Understand (comprehension) REF: 7
TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment
4. A patient has been admitted to the hospital for surgery and tells the nurse, I do not
feel comfortable leaving my children with my parents. Which action should the nurse
take next?
a. Reassure the patient that these feelings are common for parents.
b. Have the patient call the children to ensure that they are doing well.
c. Gather more data about the patients feelings about the child-care
arrangements.
d. Call the patients parents to determine whether adequate child care is
being provided.
ANS: C
Since a complete assessment is necessary in order to identify a problem and choose an
appropriate intervention, the nurses first action should be to obtain more information.
The other actions may be appropriate, but more assessment is needed before the best
intervention can be chosen.
DIF: Cognitive Level: Apply (application) REF: 6-7
OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
, MSC: NCLEX: Psychosocial Integrity
5. A patient who is paralyzed on the left side of the body after a stroke develops a
pressure ulcer on the left hip. Which nursing diagnosis is most appropriate?
a. Impaired physical mobility related to left-sided paralysis
b. Risk for impaired tissue integrity related to left-sided weakness
c. Impaired skin integrity related to altered circulation and pressure
d. Ineffective tissue perfusion related to inability to move independently
ANS: C
The patients major problem is the impaired skin integrity as demonstrated by the
presence of a pressure ulcer. The nurse is able to treat the cause of altered circulation
and pressure by frequently repositioning the patient. Although left-sided weakness is a
problem for the patient, the nurse cannot treat the weakness. The risk for diagnosis is
not appropriate for this patient, who already has impaired tissue integrity. The patient
does have ineffective tissue perfusion, but the impaired skin integrity diagnosis
indicates more clearly what the health problem is.
DIF: Cognitive Level: Apply (application) REF: 7-9
TOP: Nursing Process: Diagnosis MSC: NCLEX: Physiological Integrity
6. A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume
related to excessive diaphoresis. Which outcome would the nurse recognize as most
appropriate for this patient?
a. Patient has a balanced intake and output.
b. Patients bedding is changed when it becomes damp.
c. Patient understands the need for increased fluid intake.
d. Patients skin remains cool and dry throughout hospitalization.
ANS: A
