Lewis's Medical-Surgical Nursing, 12th Edition By Mariann M.
Harding, Jeffrey Kwong, DebraHagler Chapter 1-69:Perfect Solution
With Rationale A+
,Chapter 01: Professional Nursing
Harding: Lewis’s Medical-Surgical Nursing, 12th Edition
Multiple Choice
1. The Nurse Completes An Admission Database And Explains That The Plan Of Care And
Discharge Goals Will Be Developed With The Patient‘S Input. The Patient Asks, “How Is
This Different From What The Physician Does?” Which Response Would The Nurse
Provide?
a. “The Role Of The Nurse Is To Administer Medications And Other Treatments
PrescribedBy Your Physician.”
b. “In Addition To Caring For You While You Are Sick, The Nurses Will Help
You Plan ToMaintain Your Health.”
c. “The Nurse‘S Job Is To Collect Information And Communicate Any
Problems ThatOccur To The Physician.”
d. “Nurses Perform Many Of The Same Procedures As The Physician, But
Nurses Are With The Patients For A Longer Time Than The Physician.”
Answer: B
The American Nurses Association (Ana) Definition Of Nursing Describes The Role Of
Nurses In Promoting Health. The Other Responses Describe Dependent And Collaborative
Functions Of The Nursing Role But Do Not Accurately Describe The Nurse‘S Unique Role
In The Health Care System.
Dif: Cognitive Level: Analyze (Analysis)
Top: Nursing Process: Implementation Msc: Nclex: Safe And Effective Care Environment
2. Which Statement By The Nurse Accurately Describes The Use Of Evidence-Based Practice
(Ebp)?
a. “Patient Care Is Based On Clinical Judgment, Experience, And Traditions.”
b. “Data Are Analyzed Later To Show That The Patient Outcomes Are Consistently Met.”
c. “Research From All Published Articles Are Used As A Guide For Planning Patient Care.”
d. “Recommendations Are Based On Research, Clinical Expertise, And
Patient Preferences.”
Answer: D
Evidence-Based Practice (Ebp) Is The Use Of The Best Research-Based Evidence Combined
WithClinician Expertise And Consideration Of Patient Preferences. Clinical Judgment Based
On The Nurse‘S Clinical Experience Is Part Of Ebp, But Clinical Decision Making Should
Also Incorporate Current Research And Research-Based Guidelines. Evaluation Of Patient
Outcomes IsImportant, But Data Analysis Is Not Required To Use Ebp. All Published
Articles Do Not Provide Research Evidence; Interventions Should Be Based On Credible
Research, Preferably RandomizedControlled Studies With A Large Number Of Subjects.
Dif: Cognitive Level: Understand (Comprehension) Top: Nursing Process: Planning
Msc: Nclex: Safe And Effective Care Environment
3. Which Statement By The Nurse Provides A Clear Explanation Of The Nursing Process?
a. “The Nursing Process Is A Research Method Of Diagnosing The Patient‘S
Health CareProblems.”
b. “The Nursing Process Is Used Primarily To Explain Nursing Interventions To
OtherHealth Care Professionals.”
c. “The Nursing Process Is A Problem-Solving Tool Used To Identify And Manage The
, Patients‘ Health Care Needs.”
d. “The Nursing Process Is Based On Nursing Theory That
Incorporates TheBiopsychosocial Nature Of Humans.”
Answer: C
The Nursing Process Is A Problem-Solving Approach To The Identification And Treatment
Of Patients‘ Problems. Nursing Process Does Not Require Research Methods For Diagnosis.
The Primary Use Of The Nursing Process Is In Patient Care, Not To Establish Nursing
Theory Or ExplainNursing Interventions To Other Health Care Professionals.
Dif: Cognitive Level: Understand (Comprehension) Top: Nursing Process: Evaluation
Msc: Nclex: Safe And Effective Care Environment
4. A Patient Admitted To The Hospital For Surgery Tells The Nurse, “I Do Not Feel
ComfortableLeaving My Children With My Parents.” Which Action Would 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. Gather Information On The Patient‘S Concerns About The Child Care Arrangements.
d. Call The Patient‘S Parents To Determine Whether Adequate Child Care Is
BeingProvided.
Answer: C
Because 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 InterventionCan Be Chosen.
Dif: Cognitive Level: Analyze (Analysis)
Top: Nursing Process: Assessment Msc: Nclex: Psychosocial Integrity
5. A Patient With A Bacterial Infection Is Hypovolemic Due To A Fever And Excessive
Diaphoresis.Which Expected Outcome Would The Nurse Select For This Patient?
a. Patient Has A Balanced Intake And Output.
b. Patient‘S Bedding Is Kept Clean And Free Of Moisture.
c. Patient Understands The Need For Increased Fluid Intake.
d. Patient‘S Skin Remains Cool And Dry Throughout Hospitalization.
Answer: A
Balanced Intake And Output Gives Measurable Data Showing Resolution Of The Problem Of
Deficient Fluid Volume. The Other Statements Would Not Indicate That The Problem Of
Hypovolemia Was Resolved.
Dif: Cognitive Level: Apply (Application) Top: Nursing Process: Planning
Msc: Nclex: Physiological Integrity
6. Which Statement Describes The Purpose Of The Evaluation Phase Of The Nursing Process?
a. To Document The Nursing Care Plan In The Progress Notes Of The Health Record
b. To Determine If Interventions Have Been Effective In Meeting Patient Outcomes
c. To Decide Whether The Patient‘S Health Problems Have Been Completely Resolved
d. To Establish If The Patient Agrees That The Nursing Care Provided Was Satisfactory
Answer: B
, Evaluation Consists Of Determining Whether The Desired Patient Outcomes Have Been
Met And Whether The Nursing Interventions Were Appropriate. The Other Responses Do
Not Describe TheEvaluation Phase.
DIF: COGNITIVE LEVEL: UNDERSTAND (COMPREHENSION) TOP: NURSING
PROCESS: EVALUATIONMSC: NCLEX: SAFE AND EFFECTIVE CARE ENVIRONMENT
7. WHICH STATEMENT DESCRIBES THE PURPOSE OF THE ASSESSMENT PHASE OF
THE NURSING PROCESS?
a. TO TEACH INTERVENTIONS THAT RELIEVE HEALTH PROBLEMS
b. TO USE PATIENT DATA TO EVALUATE PATIENT CARE OUTCOMES
c. TO OBTAIN DATA TO DIAGNOSE PATIENT STRENGTHS AND PROBLEMS
d. TO HELP THE PATIENT IDENTIFY REALISTIC OUTCOMES FOR HEALTH
PROBLEMS
ANSWER: C
DURING THE ASSESSMENT PHASE, THE NURSE GATHERS INFORMATION
ABOUT THE PATIENT TO DIAGNOSEPATIENT STRENGTHS AND PROBLEMS. THE
OTHER RESPONSES ARE EXAMPLES OF THE PLANNING, INTERVENTION, AND
EVALUATION PHASES OF THE NURSING PROCESS.
DIF: COGNITIVE LEVEL: UNDERSTAND (COMPREHENSION)
TOP: NURSING PROCESS: ASSESSMENT MSC: NCLEX: SAFE AND EFFECTIVE CARE
ENVIRONMENT
8. WHEN DEVELOPING THE PLAN OF CARE, WHICH COMPONENTS WOULD THE
NURSE INCLUDE IN THE CLINICALPROBLEM STATEMENT?
a. THE PROBLEM AND THE SUGGESTED PATIENT GOALS OR OUTCOMES
b. THE PROBLEM, ITS CAUSES, AND THE SIGNS AND SYMPTOMS OF THE
PROBLEM
c. THE PROBLEM WITH THE POSSIBLE ETIOLOGY AND THE PLANNED
INTERVENTIONS
d. THE PROBLEM, ITS PATHOPHYSIOLOGY, AND THE EXPECTED OUTCOME
ANSWER: B
WHEN WRITING CLINICAL PROBLEMS OR NURSING DIAGNOSES, THE
SUBJECTIVE AS WELL AS OBJECTIVE DATA TO SUPPORT THE PROBLEM‘S
EXISTENCE SHOULD BE INCLUDED. GOALS, OUTCOMES, AND INTERVENTIONS
ARENOT INCLUDED IN THE PROBLEM STATEMENT.
DIF: COGNITIVE LEVEL: UNDERSTAND (COMPREHENSION) TOP: NURSING
PROCESS: DIAGNOSISMSC: NCLEX: SAFE AND EFFECTIVE CARE ENVIRONMENT
9. WHICH PATIENT CARE TASK WOULD THE NURSE DELEGATE TO EXPERIENCED
ASSISTIVE PERSONNEL (AP)?
a. INSTRUCT THE PATIENT ABOUT THE NEED TO ALTERNATE ACTIVITY AND
REST.
b. MONITOR LEVEL OF SHORTNESS OF BREATH OR FATIGUE AFTER
AMBULATION.
c. OBTAIN THE PATIENT‘S BLOOD PRESSURE AND PULSE RATE AFTER
AMBULATION.
d. DETERMINE WHETHER THE PATIENT IS READY TO INCREASE THE ACTIVITY
LEVEL.
ANSWER: C
AP EDUCATION INCLUDES ACCURATE VITAL SIGN MEASUREMENT.
ASSESSMENT AND PATIENT TEACHINGREQUIRE REGISTERED NURSE
EDUCATION AND SCOPE OF PRACTICE AND CANNOT BE DELEGATED.
DIF: COGNITIVE LEVEL: APPLY (APPLICATION) TOP: NURSING PROCESS:
