Test Bank Lewis Medical-Surgical Nursing: Assessment and Management of Clinical Problems 12th Edition By Harding & Kwong

,Chapter 01: Professional Nursing
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Harding: Lewis’s Medical-Surgical Nursing, s s s s 12th Edition


MULTIPLE CHOICE ss




1. The nurse completes an admission database and explains that the plan of care and
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discharge goals will be developed with the patient‗s input. The patient asks, ―How is this
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different from what the physician does?‖ Which response would the nurse
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provide?
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a. ―The role of the nurse is to administer medications and other treatments
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prescribed by your physician.‖
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b. ―In addition to caring for you while you are sick, the nurses will help you
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plan to maintain your health.‖
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c. ―The nurse‗s job is to collect information and communicate anyproblems
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thatoccur to the physician.‖
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d. ―Nurses perform many of the same procedures as the physician, but nurses ss ss ss ss ss ss ss ss ss ss ss



are with the patients for a longer time than the physician.‖
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ANS: s s B
The American Nurses Association (ANA) definition of nursing describes the
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role of nurses inpromoting health. The other responses describe dependent and
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collaborative functions of the nursing role but do not accurately describe the
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nurse‗s unique role in the health care system.
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DIF: Cognitive Level: Analyze (Analysis)
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TOP: Nursing Process: Implementation s s s s MSC: NCLEX: s s Safe s s and s s Effective
Care Environment
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2. Which statement by the nurse accurately describes
ss s s ss s s ss ss s s the use of evidence-based practice
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s s (EBP)?
a. ―Patient care is based on clinical judgment, experience, and traditions.‖
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b. ―Data are analyzed later to show that the patient outcomes are consistently met.‖
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c. ―Research from all published articles are used as a guide for planning patient care.‖
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d. ―Recommendations are based on research, clinical expertise, and ss ss ss ss ss ss ss



patient preferences.‖
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ANS: s s D
Evidence-based practice (EBP) is the use of the best research-based evidence s s s s s s s s s s s s s s s s s s s s



combined with clinician expertise and consideration of patient preferences. Clinical
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judgment based on the nurse‗s clinical experience is part of EBP, but clinical
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decision making should also incorporate current research and research-based
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guidelines. Evaluation of patient outcomes isimportant, but data analysis is not
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required to use EBP. All published articles do not provide research evidence;
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interventions should be based on credible research, preferably randomizedcontrolled
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studies with a large number of subjects.
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DIF: Cognitive Level: Understand (Comprehension) ss s s ss TOP: Nursing s s



Process: Planning MSC:
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Effective Care Environment
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3. Which statement by the nurse provides a clear explanation of the nursing process?
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a. ―The nursing process is a research method of diagnosing the patient‗s health
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ss careproblems.‖
b. ―The nursing process is used primarily to explain nursing interventions to
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ss otherhealth care professionals.‖ s s s s



c. ―The nursing process is a problem-solving tool used to identify and manage the
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, patients‗ health care needs.‖ ss ss ss



d. ―The nursing process is based on nursing theorythat incorporates
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ss the biopsychosocial nature of humans.‖
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ANS: s s C
The nursing process is a problem-solving approach to the identification and treatment
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of patients‗ problems. Nursing process does not require research methods for
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diagnosis.
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The primary use of the nursing process is in patient care, not to establish nursing
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theory or explain nursing interventions to other health care professionals.
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DIF: Cognitive Level: Understand (Comprehension) ss s s ss TOP: Nursing s s



Process: EvaluationMSC:
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Effective Care Environment
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4. A patient admitted to the hospital for surgery tells the nurse, ―I do not feel
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comfortableleaving my children with my parents.‖ Which action would
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the nurse take next?
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a. Reassure the patient that these feelings are common for parents.ss ss s s s s ss s s ss s s ss



b. Have the patient call the children to ensure that they are doing well.
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c. Gather information on the patient‗s concerns about the child care arrangements.
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d. Call the patient‗s parents to determine whether adequate child care is
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being provided.
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ANS: s s C
Because a complete assessment is necessary in order to identify a problem
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and choose an appropriate intervention, the nurse‗s first action should be to
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obtain more information. The other actions may be appropriate, but more assessment
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is needed before the best intervention can be chosen.
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DIF: Cognitive Level: Analyze (Analysis) ss ss ss



TOP: Nursing Process: Assessment MSC: ss s s s s s s NCLEX: Psychosocial Integrity ss ss




5. A patient with a bacterial infection is hypovolemic due to a fever and
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excessive diaphoresis.Which expected outcome would the nurse select
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for this patient?
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a. Patient has a balanced intake and output. ss s s ss s s ss s s



b. Patient‗s bedding is kept clean and free of moisture. ss ss ss ss s s s s ss ss



c. Patient understands the need for increased fluid intake.
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d. Patient‗s skin remains cool and dry throughout hospitalization. ss ss ss ss s s ss s s




ANS: s s A
Balanced intake and output gives measurable data showing resolution of the problem
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ofdeficient fluid volume. The other statements would not indicate that the
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problem of hypovolemia was resolved.
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DIF: Cognitive Level: Apply (Application) ss s s ss TOP: Nursing s s



Process: Planning MSC:
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Physiological Integrity
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6. Which ss statement describes the purpose of the evaluation phase of the nursing process?
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a. To ss document the nursing care plan in the progress notes of the health record
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b. To ss determine if interventions have been effective in meeting patient outcomes
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c. To ss decide whether the patient‗s health problems have been completely resolved
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d. To ss establish if the patient agrees that the nursing care provided was satisfactory
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ANS: s s B

, Evaluation consists of determining whether the desired patient outcomes have
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been met andwhether the nursing interventions were appropriate. The other
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responses do not describe theevaluation phase.
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DIF: Cognitive Level: Understand (Comprehension)
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Evaluation MSC:
ss NCLEX: Safe and Effective Care Environment
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7. Which ss statement describes the purpose of the assessment phase of the nursing process?
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a. To ss teach interventions that relieve health problems
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b. To s s use patient data to evaluate patient care outcomes
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c. To ss obtain data to diagnose patient strengths and problems
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d. To ss help the patient identify realistic outcomes for health problems
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ANS: s s C
During the assessment phase, the nurse gathers information about the patient to
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diagnose patient strengths and problems. The other responses are examples of the
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planning, intervention, and evaluation phases of the nursing process.
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DIF: Cognitive Level: Understand (Comprehension) ss ss ss



TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
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8. When developing the plan of care, which components would the nurse include in
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s s the clinical problem statement?
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a. The problem and the suggested patient goals or outcomes
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b. The problem, its causes, and the signs and symptoms of the problem
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c. The problem with the possible etiology and the planned interventions
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d. The problem, its pathophysiology, and the expected outcome
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ANS: s s B
When writing clinical problems or nursing diagnoses, the subjective as well as
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objective data to support the problem‗s existence should be included. Goals, outcomes,
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and interventions are not included in the problem statement.
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DIF: Cognitive Level: Understand (Comprehension) ss s s ss TOP: Nursing s s



Process: DiagnosisMSC:
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Effective Care Environment
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9. Which patient care task would the nurse delegate to experienced assistive personnel
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s s (AP)?
a. Instruct the patient about the need to alternate activity and rest.
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b. Monitor level of shortness of breath or fatigue after ambulation.
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c. Obtain the patient‗s blood pressure and pulse rate after ambulation.
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d. Determine whether the patient is ready to increase the activity level.
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ANS: s s C
AP education includes accurate vital sign measurement. Assessment and patient
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teaching require registered nurse education and scope of practice and
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cannot be delegated.
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DIF: Cognitive Level: Apply (Application) ss s s ss TOP: Nursing s s



Process: Planning MSC:
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Effective Care Environment
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