Introductory Medical Surgical Nursing 11th Edition by Barbara K. Tim – Test Bank, Exams of Nursing

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Introductory Medical Surgical Nursing 11th Edition

by Barbara K. Tim – Test Bank

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Introductory Medical Surgical Nursing 11th Edition by Barbara K.

Tim – Test Bank

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Sample Question

1. Which of the following is a true statement about critical thinking in nursing? A) It involves purposeful, outcome-directed thinking. B) It shows trends and patterns in client status. C) It makes judgments based on conjecture.

D) It supplies validation for reimbursement. Ans: A Feedback: In nursing, critical thinking involves purposeful, outcome-directed thinking. Critical think Providing a foundation for evaluation and quality improvement and showing trends and

2. Which of the following is involved in the implementation step of the nursing process? A) Selecting nursing interventions B) Documenting nursing care and client responses C) Documenting the plan of care D) Identifying measurable outcomes Ans: B Feedback: The implementation step in the nursing process involves documenting nursing care and interventions, documenting the plan of care, and identifying measurable outcomes.

3. Which of the following is an important element of implementation?

A) Client database B) Critical thinking C) Nursing orders D) Documentation Ans: D Feedback: An important element of implementation is documentation. The client database include history. Physical examination and diagnostic studies are not an important element of im outcome-directed thinking. Developing good critical thinking skills will make nurses mor multiple interventions. Nursing orders are specific nursing directions so that all healthca they are not an important element of implementation.

4. Which of the following pieces of information is included in the client database? A) Nursing care B) Diagnostic studies C) Plan of care D) Collaborative problems Ans: B Feedback:

The client database includes all the information obtained from the medical and nursing

database does not include nursing care, plan of care, or collaborative problems.

5. Which type of nursing diagnosis statement begins with the stem readiness for enhanced A) Health promotion B) Syndrome C) Risk D) Actual Ans: A Feedback: Health promotion nursing diagnoses reflect clinical judgment of a client’s motivation an behaviors. Risk nursing diagnoses identify potential problems and use the stem risk for , nursing diagnoses identify existing problems. Syndrome diagnoses describe specific dia collective interventions.

6. Which of the following is the highest level of human need according to Maslow (1968)? A) Physiologic B) Love and belonging C) Esteem and self-esteem

D) Self-actualization

Ans: D Feedback: The highest level need is self-actualization. The first level of need is physiological needs esteem are fourth-level needs.

7. Which phase of the nursing process enables the nurse to compare the actual outcomes A) Assessment B) Planning C) Implementation D) Evaluation Ans: D Feedback: Evaluation is assessment and review of the quality and suitability of the care given and observation and evaluation of a client’s health status. Planning involves setting prioritie specific nursing interventions, and recording the plan of care. Implementation means ca monitoring the client’s status; and assessing and reassessing the client before, during, a

8. Which of the following is a true statement about critical thinking according to Alfaro-LeF

A) It makes judgments based on conjecture. B) It is based on the medical model. C) It considers only the client’s needs. D) It is guided by professional standards and codes of ethics. Ans: D Feedback: Critical thinking is guided by professional standards and codes of ethics. It is based on p thinking makes judgments based on evidence rather than conjecture. It considers client

9. Which type of nursing diagnosis has a goal to increase well-being and enhance specific A) Health promotion B) Risk C) Wellness D) Actual Ans: A Feedback: Health promotion nursing diagnoses look for ways to enhance health. Risk nursing diagn Risk for Impaired Skin Integrity related to inactivity. In wellness

diagnoses, the diagnosti does not include related factors or supporting data. Actual nursing diagnoses identify ex

10. Which of the following identify a diagnosis associated with a cluster of other diagnoses? A) Risk nursing diagnoses B) Actual nursing diagnoses C) Syndrome diagnoses D) Health promotion nursing diagnoses Ans: C Feedback: Syndrome diagnoses identify a diagnosis associated with a cluster of other diagnoses, s problems and use the stem risk for , as in Risk for Impaired Skin Integrity related to inact of a client’s motivation and behavior to increase well- being and enhance health-seeking
11. The LPN states to an RN, “I don’t know why we have to follow a care plan. No one even What is the best response by the RN? A) “I agree with you, and we should talk to the manager about eliminating the B) “I think it is something we have always done, and we have to continue to u C) “It helps to provide a systematic method for us to plan and implement care D) “Physicians use our care plans in order to see what we are doing for the clie Ans: C

Feedback: The purpose of the nursing process is to provide a systematic method for nurses to plan learning principles of critical thinking and nursing process, it’s like using a calculator wit divide” and is why the process should be complete with the paperwork. The other two a the process.

12. A client is admitted to the hospital for control of diabetes mellitus. When does the LPN u A) When the client enters the healthcare system B) Prior to the client being discharged C) After the RN initiates the plan of care D) When the physician writes the first order for care Ans: A Feedback: The nursing process begins when a client enters the healthcare system. The other three
13. The RN is obtaining a health history and performing a physical assessment for a client w part of the nursing process does the LPN understand the RN is performing? A) Planning B) Implementation

C) Evaluation D) Assessment Ans: D Feedback: Assessment is the careful observation and evaluation of a client’s health status. The nur factors that contribute to health problems as well as client strengths. Planning is establi goals. Implementation is putting the plan into action. Evaluation is determining the clien

14. The RN develops an outcome standard of “client will ambulate with an assistive device replacement. What part of the nursing process is involved with this outcome statement? A) Assessment B) Planning C) Implementation D) Evaluation Ans: B Feedback: Establishing the outcomes and actions will help the client achieve the overall goals of ca client’s health status by the collection of data. Implementation is putting the plan into a care provided.

15. A client has been admitted to the hospital with a large sacral pressure ulcer. The physici What would be a statement on the plan of care that would address the implementation A) A 6 cm × 4 cm wound with malodorous, yellow exudate B) The client’s wound will heal by 1 cm by the end of 5 days. C) The client’s wound has healed by 0.5 cm on day 3 of wound care. D) Turn the client every 2 hours. Ans: D Feedback: Turning the client every 2 hours is implementing care to allow the pressure ulcer to heal assessment phase of the nursing process. Option B is the planning phase of the nursing process.
16. The LPN plays a vital role in the development of a nursing diagnosis for a client. What ro A) Report information that suggests actual or potential health problems. B) Examine and analyze the client database to formulate nursing diagnosis. C) Inform the physician about the specific development of the nursing diagnos D) Evaluate the effectiveness of the nursing diagnosis and how it pertains to t Ans: A Feedback:

As in other phases of the nursing process, the nurse’s role depends on his or her level o potential health problems. RNs examine and analyze the client database to formulate a nursing process and care planning of the client. The RNs role is to evaluate the effective

17. The RN is attempting to formulate a nursing diagnosis for a client but does not find whe Association (NANDA)–approved diagnosis. What is the best option for the nurse? A) Gather other data so that it will fit into a NANDA approved diagnosis. B) The nurse will have to forgo applying a nursing diagnosis. C) Pick a NANDA-approved diagnosis as long as it somewhat fits. D) Use his or her own terminology. Ans: D Feedback: If a client’s problem does not fit into any of the NANDA-approved diagnoses, the nurse c pick any diagnosis as long as it comes close to fitting, or try gathering new data so that
18. The nurse gathers data for a client who has dehydration and formulates a nursing diagn evidenced by poor skin turgor, lethargy, and altered fluid and electrolyte balance. What A) Risk nursing diagnosis B) Syndrome diagnosis C) Health promotion nursing diagnosis

D) Actual nursing diagnosis Ans: D Feedback: Actual nursing diagnoses identify existing problems, such as Urinary Retention or Anxiet a client’s motivation and behavior to increase well-being and enhance health-seeking b group and are best addressed as a group with collective interventions. Risk nursing diag Risk for Impaired Skin Integrity related to inactivity.

19. The nurse is developing a care plan for a client who has had a stroke and is unable to as top priority? A) Risk for development of a pressure ulcer B) Risk for Injury C) Ineffective Breathing Pattern D) Social Isolation Ans: C Feedback: Nurses must rank any problem that poses a threat to physiologic functioning first. For ex and Deficient Fluid Volume demand the nurse’s attention more than other diagnoses be diagnoses are second level and higher. This relates to Maslow’s hierarchy.
20. In order to establish specific and realistic outcomes so that the client does not become f

establishing these outcomes? A) The client and family B) The physician C) The certified nursing assistant (CNA) D) Case management Ans: A Feedback: The nurse includes the client and family in establishing outcomes. Outcomes are specifi frustrated, and measurable, so the nurse can reliably determine to what extent the clien management do not play a role in the development of nursing outcomes.

21. The nurse is prioritizing the care of a client who has diagnoses of uncontrolled diabetes ulcer. What need would the nurse place at the lowest level while prioritizing this client’s A) Physiologic needs B) Safety and security needs C) Love and belonging needs D) Self-actualization needs Ans: D Feedback:

Self-actualization needs are the fifth and last level. Physiologic needs are the first level, belonging needs are the third level.

22. The nurse has developed a plan of care for a client who is having a surgical procedure a the outcome statement to read: “The client will have clear lungs by the third postoperat lobe crackles and infiltrates on the chest x-ray. What conclusion does the nurse reach fo A) The outcome is achieved, the problem is solved, and the nursing orders are B) The outcome is not met, but progress is being made, and the plan of care is C) The outcome is not achieved, and the plan requires critical reevaluation an D) The outcome will be reassessed in 2 more days. Ans: C Feedback: The client has not achieved the outcome and in fact has developed pneumonia. The pla required to assist with resolving the pneumonia. The other evaluation criteria are not co
23. The nursing student says to the instructor, “I always hear about critical thinking and ho best response by the instructor? A) “If you have critical thinking skills, you won’t make mistakes.”

B) “You will never make it through nursing school without those skills.” C) “Without good critical thinking skills, you won’t be able to make a decision.

D) “Acquiring critical thinking skills will help you become more efficient and eff Ans: D Feedback: Developing good critical thinking skills will make nurses more efficient and effective at r thinking has predictable features that nurses can practice and learn. Having critical thin learned from. Options B and C are nontherapeutic responses to the student.

24. The nurse is developing a concept care map for a client with multiple medical problems. using a concept care map? A) Assessment B) Assessment/Diagnosis C) Diagnosis/Planning D) Planning/Implementation Ans: A Feedback: The first step in developing and using a concept care map involves identifying the prima second step is the assessment/diagnosis, the third step is diagnosis/planning, and the fo

25. The student nurse is developing a concept care map for her client with multiple sclerosi among the nursing diagnoses and begin to see the client holistically?

A) Assessment B) Assessment/diagnosis C) Diagnosis/Planning D) Planning/Implementation Ans: C Feedback: In diagnosis/planning, the nurse determines relationships among nursing diagnoses. It p beginning phase where the nurse begins collecting the data. In assessment/diagnosis, t at this point. Planning/implementation cannot begin until the relationship is formed.

26. The nurse understands that one of the characteristics of critical thinking is flexibility. Wh A) Listen to new ideas and other viewpoints. B) Modify priorities and adapt to change. C) Accept that answers may not come easily. D) Foresee probable outcomes. Ans: B Feedback: In order to demonstrate flexibility, the nurse must be able to modify previous priorities a viewpoints is an example of being open minded. Accepting that

answers may not come probable outcomes is an example of the ability to weigh advantages and disadvantages

27. A new graduate nurse is assigned six clients to care for on a medical unit. Without askin upset and states, “I can’t do this anymore.” What characteristic of critical thinking has t A) Show confidence B) Aware of their own limitations C) Humble D) Willing to persevere Ans: B Feedback: The new graduate has not developed the awareness of limitation and does not know wh strengths and capabilities. Being humble is not having to know everything all of the tim
28. The LPN is assisting with the admission of a client scheduled for surgery the next day. W process? A) Gathers more extensive biopsychosocial data B) Draws conclusions, uses judgment, and makes diagnosis C) Establishes priorities, sets short- and long-term goals D) Contributes to the development of care