Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. When caring for clients using evidence-informed practice, which of the following does the
nurse use?
a. Clinical judgement based on experi...
,Chapter 01: Introduction to Medical-Surgical Nursing Practice in Canada
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. When caring for clients 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 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 available evidence to provide care. Four
primary elements are: (a) clinical state, setting, and circumstances; (b) client preferences and
actions; (c) best research evidence; and (d) 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: Comprehension TOP: Nursing Process: Planning
2. Which of the following best e x p l ai ns th e nu rse s ’ pri m ar y use of the nursing process when
N R I G B.C M
providing care to clients? U S N T O
a. To explain nursing interventions to other health care professionals
b. As a problem-solving tool to identify and treat clients’ health care needs
c. As a scientific-based process of diagnosing the client’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 clients’ problems. Diagnosis is only one phase of the nursing process. The
primary use of the nursing process is in client care, not to establish nursing theory or explain
nursing interventions to other health care professionals.
3. The nurse is caring for a critically ill client 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
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 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.
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.
c. Call the neighbour to determine whether adequate childcare is being provided.
d. 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.
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 fN
Uo rRt Sh I
i s cG B.C
NlienTt? OM
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 client’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 client. Although left-sided weakness is a problem for the client,
the nurse cannot treat the weakness. The “risk 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.
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
outcome?
a. Client has a balanced intake and output.
b. Client’s bedding is changed when it becomes damp.
, c. Client understands the need for increased fluid intake.
d. Client’s skin remains cool and dry throughout hospitalization.
ANS: A
This statement gives measurable data showing resolution of the problem of deficient fluid
volume that was identified in the nursing diagnosis statement. The other statements would not
indicate that the problem of deficient fluid volume was resolved.
DIF: Cognitive oLevel: oComprehension TOP: o Nursing oProcess: oEvaluation
8. Which oof othe ofollowing owould othe onurse operform oduring othe oassessment ophase oof othe
onursing oprocess?
a. Obtains odata owith owhich oto odiagnose oclient oproblems
b. Uses oclient odata oto odeveloNp op R
r ioriIt y onGursiBng.dCiagM
noses
c. U S oNclient
Teaches ointerventions oto orelieve T ohealth oproblems
d. Assists othe oclient oto oidentify orealistic ooutcomes oto ohealth oproblems
ANS: o A
During othe oassessment ophase, othe onurse ogathers oinformation oabout othe oclient. oThe
oother oresponses oare oexamples oof othe ointervention, odiagnosis, oand oplanning ophases oof
othe onursing oprocess.
DIF: Cognitive oLevel: oKnowledge TOP: o Nursing oProcess: oAssessment
9. Which oof othe ofollowing ois oan oexample oof oa ocorrectly owritten onursing odiagnosis ostatement?
a. Altered otissue operfusion orelated oto oheart ofailure
b. Risk ofor oimpaired otissue ointegrity orelated oto osacral oredness
c. Ineffective ocoping orelated oto oinsufficient osense oof ocontrol.
d. Altered ourinary oelimination orelated oto ourinary otract oinfection
ANS: o C
This odiagnosis ostatement oincludes oa oNANDA onursing odiagnosis oand oan oetiology othat
odescribes oa oclient’s oresponse oto oa ohealth oproblem othat ocan obe otreated oby onursing. oThe
ouse oof oa omedical odiagnosis o(as oin othe oresponses obeginning o“Altered otissue operfusion”
oand o“Altered ourinary oelimination”) ois onot oappropriate. oThe oresponse obeginning o“Risk
ofor oimpaired otissue ointegrity” ouses othe odefining ocharacteristics oas othe oetiology.
DIF: Cognitive oLevel: oComprehension TOP: o Nursing oProcess: oDiagnosis
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