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Test Bank - Lewis’s Medical-Surgical Nursing in Canada, 5th Edition ( Tyerman, 2025) All Chapters 1-72|| Newest Edition ||Complete A+ Guide$17.99
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Test Bank - Lewis’s Medical-
Surgical Nursing in Canada, 5th
Edition ( Tyerman, 2025) All
Chapters 1-72|| Newest Edition
,Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada Lewis:
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Medical-Surgical Nursing in Canada, 5th Canadian Edition
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MULTIPLE CHOICE f
1. When caring for clients using evidence-informed practice, which of the following does the
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nurse use?
f f
a. Clinical judgement based on experience f f f f
b. Evidence from a clinical research study f f f f f
c. The best available evidence to guide clinical expertise
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d. Evaluation of data showing that the client outcomes are met f f f f f f f f f
ANS: C f
Evidence-informed nursing practice is a continuous interactive process involving the explicit, f f f f f f f f f f
conscientious, and judicious consideration of the best available evidence to provide care. Four
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primary elements are: (a) clinical state, setting, and circumstances; (b) client preferences and
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actions; (c) best research evidence; and (d) health care resources. Clinical judgement based on
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the nurse’s clinical experience is part of EIP, but clinical decision making also should
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incorporate current research and research-based guidelines. Evidence from one clinical
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research study does not provide an adequate substantiation for interventions. Evaluation of
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client outcomes is important, but interventions should be based on research from randomized
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control studies with a large number of subjects.
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DIF: Cognitive Level: Comprehension f f TOP: Nursing Process: Planning f f f
2. Which of the following best eNxp lR
f ainsIt heGnu B
f r se.s’Cpr iMmar y use of the nursing process when
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providing care to clients? USNT Of f f f f f
a. To explain nursing interventions to other health care professionals
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b. As a problem-solving tool to identify and treat clients’ health care needs
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c. As a scientific-based process of diagnosing the client’s health care problems
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d. To establish nursing theory that incorporates the biopsychosocial nature of humans
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ANS: B f
The nursing process is an assertive problem-solving approach to the identification and
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treatment of clients’ problems. Diagnosis is only one phase of the nursing process. The primary
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use of the nursing process is in client care, not to establish nursing theory or explain nursing
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interventions to other health care professionals.
f f f f f f
DIF: Cognitive Level: Comprehension f f TOP: Nursing Process: Implementation f f f
3. The nurse is caring for a critically ill client in the intensive care unit and plans an every 2-hour
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turning schedule to prevent skin breakdown. Which type of nursing function is demonstrated
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with this turning schedule?
f f f f
a. Dependent
b. Cooperative
c. Independent
d. Collaborative
ANS: D f
, When implementing collaborative nursing actions, the nurse is responsible primarily for
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monitoring for complications of acute illness or providing care to prevent or treat
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complications. Independent nursing actions are focused on health promotion, illness
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prevention, and client advocacy. A dependent action would require a physician order to
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implement. Cooperative nursing functions are not described as one of the formal nursing
f f f f f f f f f f f f f
functions.
f
DIF: Cognitive Level: Application f f TOP: Nursing Process: Implementation f f f
4. The nurse is caring for a client who has been admitted to the hospital for surgery and tells the
f f f f f f f f f f f f f f f f f f
nurse, “I do not feel right about leaving my children with my neighbour.” Which action should
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the nurse take next?
f f f f
a. Reassure the client that these feelings are common for parents. f f f f f f f f f
b. Have the client call the children to ensure that they are doing well.
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c. Call the neighbour to determine whether adequate childcare is being provided.
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d. Gather more data about the client’s feelings about the childcare arrangements.
f f f f f f f f f f
ANS: D f
Since a complete assessment is necessary in order to identify a problem and choose an
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appropriate intervention, the nurse’s first action should be to obtain more information. The
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other actions may be appropriate, but more assessment is needed before the best intervention can
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be chosen.
f f
DIF: Cognitive Level: Application f f TOP: Nursing Process: Assessment f f f
5. The nurse is caring for a client who has left-sided paralysis as the result of a stroke and
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assesses a pressure injury on the c l i e nt ’ s l e ft h ip . W hich of the following is the most
appropriate nursing diagnosisN fURo r t ShIi s cNGl i e nT
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Bt ?. CO M
f
f
f
f
f
f
f f
f f f f f f f
a. Impaired physical mobility related to decrease in muscle control (left-sided f f f f f f f f f
paralysis)
f
b. Risk for impaired tissue integrity as evidenced by insufficient knowledge about
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protecting tissue integrity
f f f
c. Impaired skin integrity related to pressure over bony prominence (impaired f f f f f f f f f
circulation)
f
d. Ineffective tissue perfusion related to sedentary lifestyle f f f f f f
ANS: C f
The client’s major problem is the impaired skin integrity as demonstrated by the presence of a
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pressure injury. The nurse is able to treat the cause of altered circulation and pressure by
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frequently repositioning the client. Although left-sided weakness is a problem for the client, the
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nurse cannot treat the weakness. The “risk for” diagnosis is not appropriate for this client, who
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already has impaired tissue integrity. The client does have ineffective tissue perfusion, but the
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impaired skin integrity diagnosis indicates more clearly what the health problem is.
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DIF: Cognitive Level: Application f f TOP: Nursing Process: Diagnosis f f f
6. The nurse caring for a client with an infection has a nursing diagnosis of deficient fluid
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volume related to excessive diaphoresis. Which of the following is an appropriate client
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outcome?
f
a. Client has a balanced intake and output. f f f f f f
b. Client’s bedding is changed when it becomes damp. f f f f f f f
, c. Client understands the need for increased fluid intake.
f f f f f f f
d. Client’s skin remains cool and dry throughout hospitalization.
f f f f f f f
ANS: A f
This statement gives measurable data showing resolution of the problem of deficient fluid
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volume that was identified in the nursing diagnosis statement. The other statements would not
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indicate that the problem of deficient fluid volume was resolved.
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DIF: Cognitive Level: Application f f TOP: Nursing Process: Planning f f f
7. Which of the following represents a nursing activity that is carried out during the evaluation
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f phase of the nursing process?
f f f f
a. Determining if interventions have been effective in meeting client outcomes f f f f f f f f f
b. Documenting the nursing care plan in the progress notes in the medical record f f f f f f f f f f f f
c. Deciding whether the client’s health problems have been completely resolved
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d. Asking the client to evaluate whether the nursing care provided was satisfactory
f f f f f f f f f f f
ANS: A f
Evaluation consists of determining whether the desired client outcomes have been met and
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whether the nursing interventions were appropriate. The other responses do not describe the
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evaluation phase.
f f
DIF: Cognitive Level: Comprehension f f TOP: Nursing Process: Evaluation f f f
8. Which of the following would the nurse perform during the assessment phase of the nursing
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process?
f
a. Obtains data with which to diagnose client problems
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b. Uses client data to develoN
p pR
r ior iIt y nGursiBng.dCiagM
f
U S client
c. Teaches interventions to relieve f
O noses
N T health problems f f f
f
f
f
f f
f
f
f
f f
d. Assists the client to identify realistic outcomes to health problems
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ANS: A f
During the assessment phase, the nurse gathers information about the client. The other
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responses are examples of the intervention, diagnosis, and planning phases of the nursing
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process.
f
DIF: Cognitive Level: Knowledge f f TOP: Nursing Process: Assessment f f f
9. Which of the following is an example of a correctly written nursing diagnosis statement?
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a. Altered tissue perfusion related to heart failure
f f f f f f
b. Risk for impaired tissue integrity related to sacral redness
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c. Ineffective coping related to insufficient sense of control. f f f f f f f
d. Altered urinary elimination related to urinary tract infection
f f f f f f f
ANS: C f
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that describes a
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client’s response to a health problem that can be treated by nursing. The use of a medical
f f f f f f f f f f f f f f f f f
diagnosis (as in the responses beginning “Altered tissue perfusion” and “Altered urinary
f f f f f f f f f f f f
elimination”) is not appropriate. The response beginning “Risk for impaired tissue integrity”
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uses the defining characteristics as the etiology.
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DIF: Cognitive Level: Comprehension f f TOP: Nursing Process: Diagnosis f f f
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