Lewis Medical Surgical Nursing in Canada 5th Edition – Test Bank

Lewis Medical Surgical Nursing in Canada 5th Edition – Test Bank

Chapter 01: Introduction to Medical-Surgical Nursing Practice in Ca Lewis: Medical-Surgical Nursing in Canada, 5th Canadian Edition

Medical-Surgical Nursing in Canada

TEST BANK

MULTIPLE CHOKE

1. When caring for clients using evidence-informed practice, which of the following does the name use?

Clinical judgement based on experience Evidence from a clinical research study

b. c. The best available evidence to guide clinical expertise

4. Evaluation of data showing that the client outcomes are met

ANS: C

Evidence-informed nursing practice is a continuous interactive process involving the explicit, conscientious, and judicious consideration of the best availabile evidence to provide care. Four primary elements are: (1) clinical state, seming, and circumstances; (b) client preferences and actions; (c) best research evidence; and (6) 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 client outcomes is important, but interventions should be based on research from randomized control studies with a large number of subjects.

DIF: Cognitive Level Compression

TOP Naning Process Planning

2. Which of the following best explains theres primary use of the nursing process when providing care to clients?

To explain using interventions to other health care professionals

As a groblem-solving tool to identify and treat clients health care needs

As a scientific-based process of diagnosing the client’s health care problems

4. 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 clients problems. Diagnosis is only one phase of the nursing process. The primary use of the nursing process is inclient care, not to establishing theory or explain nursing innervestions to other health care professionals.

DD: Cognitive Level: Comperbesnica

TOP: Nursing Process Implementation

3. The nurse is caring for critically ill client in the intensive care unit and plans an every 2-hour nursing schedule to prevent skin breakdown. Which type of nursing function is demonstrated with this tuming schedule?

Dependent

Cooperative

Independent

4. Collaborative

ANS: D

When implementing collaborative nursing actions, the nurse is responsible primarily for monitoring for complications of acute illness or groviding care to prevent or treat complications. Independent nursing actions are focused on health promotion, illness pervention, and client advocacy. A dependent action would require a physician order to implement. Cooperative nursing functions are not described as one of the formal nursing functions

DO: Cognitive Level: Application

TOP: Nanning Pro

4. The nurse is caring for a client 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 client that these feelings are common for parents.

b. Have the client call the children to ensure that they are doing well.

Call the neighbour to determine whether adequate childcare is being provided

4. Gather more data about the client’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

DC: Cognitive Level: Application

TOP: Nuning Process

5. The nurse is caring for a client who has left-sided paralysis as the result of a stroke and assesses a pressure injury on the client’s left hip. Which of the following is the most appropriate nursing diagnosis for this client?

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 gressure over bony prominence (impaired circulation)

Ineffective tissue perfusion related to sedentary lifestyle

ANS: C

The client’s major problem is the impaired skin integrity as demonstrated by the presence of a pressure injury. There is able to treat the cause of altered circulation and gesse by frequently repositioning the client. Although leth-sided weakness is a problem for the client, the nurse cannot treat the weakness. The “nisk for diagnosis is not appropriate for this client, who already has impaired tissue integrity. The client does have ineffective tissue perfusion, but the impaired skin integrity diagnosis indicates more clearly what the health problem is

D: Cognitive Level: Application

TOP ProD

6. The nurse caring for a client with an infection has a nursing diagnosis of deficient fluid volume related to excessive diaphoresis Which of the following is an appropriate client ouncome?

Client has a balanced intake and output

b. Cheat’s bedding is changed when it becomes damp

c. Chest understands the need for increased toid intake.

4. Chest’s skin remains cool and dry throughout hospitalization

ANS: A

This statement gives measurable data showing resolution of the problem of deficientuid volume that was identified in the surving diagnosis statement. The other statements would not indicate that the problem of deficient fluid volume was resolved.

DIF: Cognitive Level Application

TOP: Non-Processing

7. Which of the following represents a nursing activity that is carried out during the evaluation phase of the using process?

a. Determining if interventions have been effective in meeting client outcomes

Documenting the nursing careglan in the progress notes in the medical record

Deciding whether the client’s health problems have been completely resolved

4. Asking the client to evaluate whether the nursing care provided was satisfactory

ANS: A

Evaluation consists of determining whether the desired client outcomes have been met and whether the sursing interventions were appropriate. The other responses do not describe the evaluation phase

DOF: Cognitive Level Compression

TOP: Nursing Process: auation

8. Which of the following would the nurse perform during the assessment phase of the nursing process?

a. Obtains data with which to diagnose client problems

b. Uses client data to develop priority uning diagnoses

Teaches interventions to relieve chest health problems

Assists the client to identify realistic outcomes to health problems

ANS: A

During the assessment phase, the nurse gathers information about the client. The other responses are examples of the intervention, diagnos, and planning phases of the nursing process

DIF: Cognitive Level Kowledge

TOP: Noning Procen: Аленше

9. Which of the following is an example of a correctly wrimen sursing diagnosis statement?

Altered tissue perfusion related to be fre

Risk for impaired tissue integrity sellated to sacral redness

Ineffective coping related to insufficient sense of control.

4. Altered urinary elimination sellated to urinary tract infection

ANS: C

This diagnosis statement includes a NANDA ring diagnosis and an ethology that describes a chent’s response toa health problem that can be treated by using. The use of a medical diagnosis (as in the riponses beginning “Altered tissue perfusion” and “Altered trinary elimination) is not appropriate. The response beginning “Risk for impaired tissue integaty uses the defining characteristics as the etiology