Chapter 1: Introduction to Medical-Surgical Nursing Practice:
Lewis’s Medical-Surgical Nursing, 5th Edition
1. Which of the following represents a nursing activity that is carried out during the
evaluation phase of the nursing process?
A. Determining if interventions have been effective in meeting patient outcomes.
B. Documenting the nursing care plan in the progress notes in the medical record.
C. Deciding whether the patient's health problems have been completely resolved.
D. Asking the patient to evaluate whether the nursing care provided was satisfactory.
Answer: A
Explanation: Evaluation involves determining whether the nursing interventions were
effective in achieving the desired patient outcomes. Documentation (Option B) occurs
throughout the process. While evaluating resolution of problems (Option C) is related, the
formal evaluation phase focuses on the effectiveness of the plan of care. Patient satisfaction
(Option D) is part of evaluation but is not the primary focus of the clinical evaluation phase.
2. Which of the following is an example of a correctly written nursing diagnosis
statement?
A. Altered tissue perfusion related to heart failure
B. Risk for impaired tissue integrity related to sacral redness
C. Ineffective coping related to insufficient sense of control
D. Altered urinary elimination related to urinary tract infection
Answer: C
Explanation: This statement correctly uses a NANDA-I nursing diagnosis and links it to an
etiology that is a patient's response to a health problem and can be addressed by nursing
interventions. Options A and D incorrectly use medical diagnoses ("heart failure," "urinary
tract infection") as the etiology. Option B incorrectly uses the defining characteristic ("sacral
redness") as the etiology instead of the cause of the risk.
3. The nurse is caring for a patient with a new diagnosis of pneumonia and explains to
the patient that together they will plan the patient's care and set goals for discharge.
The patient asks, "How is that different from what the doctor does?" Which response
by the nurse is most appropriate?
A. "The role of the nurse is to administer medications and other treatments prescribed by
your doctor."
B. "The nurse's job is to help the doctor by collecting data and communicating when there are
,problems."
C. "Nurses perform many of the procedures done by physicians, but nurses are here in the
hospital for a longer time than doctors."
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."
Answer: D
Explanation: This response is consistent with the Canadian Nurses Association (CNA)
definition of nursing, which describes nursing as working autonomously and collaboratively
to enable individuals to achieve their optimal level of health. It encompasses health
promotion and maintenance, not just the treatment of illness. The other options describe only
dependent or collaborative functions and do not fully capture the scope of nursing practice.
4. Which of these tasks is appropriate for the registered nurse to delegate to an
unregulated care provider?
A. Perform a sterile dressing change for an infected wound.
B. Complete the patients' initial bath.
C. Teach a patient about the effects of prescribed medications.
D. Document patient teaching about a routine surgical procedure.
Answer: B
Explanation: Providing personal care, such as bathing a patient, is within the scope of
practice for an unregulated care provider. Sterile procedures (Option A), patient teaching
(Option C), and documenting the initial assessment and plan of care (Option D) require the
knowledge and skill of a registered nurse.
5. The nurse is caring for a patient who has been admitted to the hospital for surgery
and tells the nurse, "I do not feel right about leaving my children with my neighbour."
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. Call the neighbour to determine whether adequate childcare is being provided.
D. Gather more data about the patient's feelings about the childcare arrangements.
Answer: D
Explanation: The first step of the nursing process is assessment. To identify the problem and
choose an appropriate intervention, the nurse must first gather more information about the
patient's specific concerns. The other actions may be appropriate later, but they are
interventions that should not be implemented without a proper assessment.
, 6. Which of the following best explains the nurse's primary use of the nursing process
when providing care to patients?
A. To explain nursing interventions to other health care professionals
B. As a problem-solving tool to identify and treat patients' health care needs
C. As a scientific-based process of diagnosing the patient's health care problems
D. To establish nursing theory that incorporates the biopsychosocial nature of humans
Answer: B
Explanation: The nursing process is fundamentally a systematic, problem-solving approach
used to identify and address patients' healthcare needs. While it involves diagnosis (Option
C), that is only one phase. Its primary use is in direct patient care, not in explaining
interventions (Option A) or establishing theory (Option D).
7. Which of the following includes the components required for a complete nursing
diagnosis statement?
A. A problem and the suggested patient goals or outcomes
B. A problem, its cause, and objective data that support the problem
C. A problem with all its possible causes and the planned interventions
D. A problem with its etiology and the signs and symptoms of the problem
Answer: D
Explanation: A complete nursing diagnosis statement uses the PES format, which includes
the Problem, Etiology (cause), and Signs/Symptoms (defining characteristics). Outcomes
(Option A) and interventions (Option C) are not part of the diagnosis statement. Option B is
incomplete as it does not explicitly include both subjective and objective signs and
symptoms.
8. The nurse is caring for a patient who has left-sided paralysis as the result of a stroke
and assesses a pressure injury on the patient's left hip. Which of the following is the
most appropriate nursing diagnosis for this patient?
A. Impaired physical mobility related to decrease in muscle control (left-sided paralysis)
B. Risk for impaired tissue integrity as evidenced by insufficient knowledge about protecting
tissue integrity
C. Impaired skin integrity related to pressure over bony prominence (impaired circulation)
D. Ineffective peripheral tissue perfusion related to sedentary lifestyle
Answer: C
Explanation: The patient has an actual problem—a pressure injury—making "Impaired skin
integrity" the most accurate diagnosis. The etiology (pressure over a bony prominence due to
impaired circulation from paralysis) is directly treatable by nursing interventions like
Lewis’s Medical-Surgical Nursing, 5th Edition
1. Which of the following represents a nursing activity that is carried out during the
evaluation phase of the nursing process?
A. Determining if interventions have been effective in meeting patient outcomes.
B. Documenting the nursing care plan in the progress notes in the medical record.
C. Deciding whether the patient's health problems have been completely resolved.
D. Asking the patient to evaluate whether the nursing care provided was satisfactory.
Answer: A
Explanation: Evaluation involves determining whether the nursing interventions were
effective in achieving the desired patient outcomes. Documentation (Option B) occurs
throughout the process. While evaluating resolution of problems (Option C) is related, the
formal evaluation phase focuses on the effectiveness of the plan of care. Patient satisfaction
(Option D) is part of evaluation but is not the primary focus of the clinical evaluation phase.
2. Which of the following is an example of a correctly written nursing diagnosis
statement?
A. Altered tissue perfusion related to heart failure
B. Risk for impaired tissue integrity related to sacral redness
C. Ineffective coping related to insufficient sense of control
D. Altered urinary elimination related to urinary tract infection
Answer: C
Explanation: This statement correctly uses a NANDA-I nursing diagnosis and links it to an
etiology that is a patient's response to a health problem and can be addressed by nursing
interventions. Options A and D incorrectly use medical diagnoses ("heart failure," "urinary
tract infection") as the etiology. Option B incorrectly uses the defining characteristic ("sacral
redness") as the etiology instead of the cause of the risk.
3. The nurse is caring for a patient with a new diagnosis of pneumonia and explains to
the patient that together they will plan the patient's care and set goals for discharge.
The patient asks, "How is that different from what the doctor does?" Which response
by the nurse is most appropriate?
A. "The role of the nurse is to administer medications and other treatments prescribed by
your doctor."
B. "The nurse's job is to help the doctor by collecting data and communicating when there are
,problems."
C. "Nurses perform many of the procedures done by physicians, but nurses are here in the
hospital for a longer time than doctors."
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."
Answer: D
Explanation: This response is consistent with the Canadian Nurses Association (CNA)
definition of nursing, which describes nursing as working autonomously and collaboratively
to enable individuals to achieve their optimal level of health. It encompasses health
promotion and maintenance, not just the treatment of illness. The other options describe only
dependent or collaborative functions and do not fully capture the scope of nursing practice.
4. Which of these tasks is appropriate for the registered nurse to delegate to an
unregulated care provider?
A. Perform a sterile dressing change for an infected wound.
B. Complete the patients' initial bath.
C. Teach a patient about the effects of prescribed medications.
D. Document patient teaching about a routine surgical procedure.
Answer: B
Explanation: Providing personal care, such as bathing a patient, is within the scope of
practice for an unregulated care provider. Sterile procedures (Option A), patient teaching
(Option C), and documenting the initial assessment and plan of care (Option D) require the
knowledge and skill of a registered nurse.
5. The nurse is caring for a patient who has been admitted to the hospital for surgery
and tells the nurse, "I do not feel right about leaving my children with my neighbour."
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. Call the neighbour to determine whether adequate childcare is being provided.
D. Gather more data about the patient's feelings about the childcare arrangements.
Answer: D
Explanation: The first step of the nursing process is assessment. To identify the problem and
choose an appropriate intervention, the nurse must first gather more information about the
patient's specific concerns. The other actions may be appropriate later, but they are
interventions that should not be implemented without a proper assessment.
, 6. Which of the following best explains the nurse's primary use of the nursing process
when providing care to patients?
A. To explain nursing interventions to other health care professionals
B. As a problem-solving tool to identify and treat patients' health care needs
C. As a scientific-based process of diagnosing the patient's health care problems
D. To establish nursing theory that incorporates the biopsychosocial nature of humans
Answer: B
Explanation: The nursing process is fundamentally a systematic, problem-solving approach
used to identify and address patients' healthcare needs. While it involves diagnosis (Option
C), that is only one phase. Its primary use is in direct patient care, not in explaining
interventions (Option A) or establishing theory (Option D).
7. Which of the following includes the components required for a complete nursing
diagnosis statement?
A. A problem and the suggested patient goals or outcomes
B. A problem, its cause, and objective data that support the problem
C. A problem with all its possible causes and the planned interventions
D. A problem with its etiology and the signs and symptoms of the problem
Answer: D
Explanation: A complete nursing diagnosis statement uses the PES format, which includes
the Problem, Etiology (cause), and Signs/Symptoms (defining characteristics). Outcomes
(Option A) and interventions (Option C) are not part of the diagnosis statement. Option B is
incomplete as it does not explicitly include both subjective and objective signs and
symptoms.
8. The nurse is caring for a patient who has left-sided paralysis as the result of a stroke
and assesses a pressure injury on the patient's left hip. Which of the following is the
most appropriate nursing diagnosis for this patient?
A. Impaired physical mobility related to decrease in muscle control (left-sided paralysis)
B. Risk for impaired tissue integrity as evidenced by insufficient knowledge about protecting
tissue integrity
C. Impaired skin integrity related to pressure over bony prominence (impaired circulation)
D. Ineffective peripheral tissue perfusion related to sedentary lifestyle
Answer: C
Explanation: The patient has an actual problem—a pressure injury—making "Impaired skin
integrity" the most accurate diagnosis. The etiology (pressure over a bony prominence due to
impaired circulation from paralysis) is directly treatable by nursing interventions like
