PN
Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada
Tyerman: Lewis’s Medical-Surgical Nursing in Canada, 5th Edition
MULTIPLE CHOICE
1. When caring for patients using evidence-informed practice, which of the following does the
nurse use?
a. Clinical judgement based on experience
b. Evidence from a clinical research study
c. The best available evidence to guide clinical expertise
d. Evaluation of data showing that the patient outcomes are met
ANS: C
Evidence-informed nursing practice is a continuous interactive process involving the explicit,
conscientious, and judicious consideration of the best available evidence to provide care. Four
primary elements are: (1) clinical state, setting, and circumstances; (2) patient preferences and
actions; (3) best research evidence; and (4) health care resources. Clinical judgement based on
the nurse’s clinical experience is part of EIP, but clinical decision making also should
incorporate current research and research-based guidelines. Evidence from one clinical
research study does not provide an adequate substantiation for interventions. 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: Comprehension TOP: Nursing Process: Planning
2. Which of the following best explains the nurses’ 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
ANS: B
The nursing process is an assertive 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: Comprehension TOP: Nursing Process: Implementation
3. The nurse is caring for a critically ill patient in the intensive care unit and plans an every
2-hour turning schedule to prevent skin breakdown. Which type of nursing function is
demonstrated with this turning schedule?
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
, PN
ANS: D
When implementing collaborative nursing actions, the nurse is responsible primarily for
monitoring for complications of acute illness or providing care to prevent or treat
complications. Independent nursing actions are focused on health promotion, illness
prevention, and patient advocacy. A dependent action would require a physician order to
implement. Cooperative nursing functions are not described as one of the formal nursing
functions.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
4. 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.
ANS: D
Since a complete assessment is necessary in order to identify a problem and choose an
appropriate intervention, the nurse’s 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: Application TOP: Nursing Process: Assessment
5. 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 tissue perfusion related to sedentary lifestyle
ANS: C
The patient’s major problem is the impaired skin integrity as demonstrated by the presence of
a pressure injury. 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: Application TOP: Nursing Process: Diagnosis
Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada
Tyerman: Lewis’s Medical-Surgical Nursing in Canada, 5th Edition
MULTIPLE CHOICE
1. When caring for patients using evidence-informed practice, which of the following does the
nurse use?
a. Clinical judgement based on experience
b. Evidence from a clinical research study
c. The best available evidence to guide clinical expertise
d. Evaluation of data showing that the patient outcomes are met
ANS: C
Evidence-informed nursing practice is a continuous interactive process involving the explicit,
conscientious, and judicious consideration of the best available evidence to provide care. Four
primary elements are: (1) clinical state, setting, and circumstances; (2) patient preferences and
actions; (3) best research evidence; and (4) health care resources. Clinical judgement based on
the nurse’s clinical experience is part of EIP, but clinical decision making also should
incorporate current research and research-based guidelines. Evidence from one clinical
research study does not provide an adequate substantiation for interventions. 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: Comprehension TOP: Nursing Process: Planning
2. Which of the following best explains the nurses’ 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
ANS: B
The nursing process is an assertive 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: Comprehension TOP: Nursing Process: Implementation
3. The nurse is caring for a critically ill patient in the intensive care unit and plans an every
2-hour turning schedule to prevent skin breakdown. Which type of nursing function is
demonstrated with this turning schedule?
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
, PN
ANS: D
When implementing collaborative nursing actions, the nurse is responsible primarily for
monitoring for complications of acute illness or providing care to prevent or treat
complications. Independent nursing actions are focused on health promotion, illness
prevention, and patient advocacy. A dependent action would require a physician order to
implement. Cooperative nursing functions are not described as one of the formal nursing
functions.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
4. 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.
ANS: D
Since a complete assessment is necessary in order to identify a problem and choose an
appropriate intervention, the nurse’s 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: Application TOP: Nursing Process: Assessment
5. 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 tissue perfusion related to sedentary lifestyle
ANS: C
The patient’s major problem is the impaired skin integrity as demonstrated by the presence of
a pressure injury. 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: Application TOP: Nursing Process: Diagnosis
