Burke: Medical–Surgical Nursing Care, 4e Chapter 1 Nursing in the 21st Century 1. While preparing to conduct an assessment the client asks why nurses assess when the physician will as well. How should the nurse respond? 1. The physician will treat with procedures. 2. The physician does not really assess. 3. The nurse treats the client’s response to illness. 4. The nurse assesses to determine needed medications. Answer: 3 Rationale: 1. The physician does treat with procedures, but this does not answer the client’s question. 2. The physician assesses the client based on the client’s need. 3. The focus of medical–surgical nursing is the adult patient’s response to actual or potential disruptions in health. 4. The physician, not the nurse, orders medications. Cognitive Level: Application Client Need: Safe and Effective Care Environment Nursing Process: Assessment Learning Outcome: 1-1 2. The nurse is conducting an assessment of a 65-year-old client who has come for an annual assessment. For which reasons should the nurse anticipate providing immunizations to the client? (Select all that apply.) 1. Promoting client health 2. Caring for the client’s illness 3. Maintaining the client’s health 4. Alleviating the client’s suffering 5. Caring for the client’s family Answer: 1; 3 Rationale: 1. Providing immunizations is an example of promoting health. © 2016 by Pearson Education, Inc. Burke, Testgen for Medical-Surgical Nursing Care, 4 th Edition 2. The client receiving immunizations is not generally ill. 3. Immunizations help to maintain the client’s health status. 4. The client having an annual assessment is usually not suffering. 5. Immunizing a client is not an example of care of the family. Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Planning Learning Outcome: 1-1 3. The nurse performs daily, routine equipment checks to detect possible malfunction. Which core competency is the nurse demonstrating with this action? 1. Providing agency-centered care 2. Working on an interdisciplinary team 3. Using information technology 4. Applying quality improvement principles Answer: 4 Rationale: 1. Nurses provide patient-centered care. 2. The nurse is functioning alone when inspecting equipment. 3. Information technology is the use of computers during health care. 4. Part of the responsibility of the nurse is to ensure the client’s safety by inspecting equipment used during care. This is a quality improvement principle. Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Implementation Learning Outcome: 1-1 4. A client who is experiencing abdominal pain is being assessed by the Emergency Department nurse. The nurse asks the client to describe the pain and the client’s usual means of relieving pain. The nurse is providing: 1. a nursing diagnosis. 2. client-centered care. 3. health promotion. © 2016 by Pearson Education, Inc. Burke, Testgen for Medical-Surgical Nursing Care, 4 th Edition 4. health maintenance. Answer: 2 Rationale: 1. A nursing diagnosis is made after the assessment is completed. 2. The nurse is providing client-centered care by asking the client about the perception of pain and the client’s usual methods of relief. 3. Health promotion might include assisting the client to alter risk factors for a disease. 4. Immunization is an example of health maintenance. Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome: 1-2 5. The nurse plans to teach a client who lives with extended family about safety issues in the home. The nurse is: 1. providing disease management. 2. relieving pain and suffering. 3. adapting care to the needs of the client. 4. advocating for lifestyle changes for the client. Answer: 3 Rationale: 1. There is no evidence that this client has a disease. 2. Relieving pain and suffering might include administering pain medications. 3. The nurse is adapting care by advocating for client safety in the home. 4. Lifestyle changes would include issues such as diet changes or exercise. Cognitive Level: Application Client Need: Safe, Effective Care Environment Nursing Process: Planning Learning Outcome: 1-2 6. While planning care for a client with a chronic disease the nurse asks the client about food preferences when discussing needed lifestyle changes. In what way is the nurse providing client-centered care? 1. Allowing the client to assume the primary role in planning 2. Planning care for the client © 2016 by Pearson Education, Inc. Burke, Testgen for Medical-Surgical Nursing Care, 4 th Edition 3. Following the care ordered by the dietician 4. Assessing the client’s needs Answer: 1 Rationale: 1. The nurse is providing client centered-care by allowing the client to assume the primary role in the planning process. 2. The nurse is planning care, but is including the client in the plan. 3. The doctor orders the diet for the client. 4. The nurse is planning care, not assessing. Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Nursing Process: Planning Learning Outcome: 1-2 7. After hearing a diagnosis a client requests a second opinion. The nurse supports and promotes the client’s rights. In what capacity is the nurse acting for the client? 1. Teacher 2. Supporter 3. Advisor 4. Advocate Answer: 4 Rationale: 1. The nurse assumes the role of teacher when providing the client with information. 2. Supporting the client means that the nurse offers encouragement when the client makes decisions. 3. Nurses are discouraged from advising the client. The role of the nurse is to present the available options and the consequences of each choice. 4. As an advocate, the nurse protects the client’s right to self-determination, one of which is seeking a second opinion. Cognitive Level: Analysis Client Need: Psychosocial Integrity Nursing Process: Implementation Learning Outcome: 1-3 © 2016 by Pearson Education, Inc. Burke, Testgen for Medical-Surgical Nursing Care, 4 th Edition 8. A client is being discharged, and needs instructions on wound care. When planning to teach the client, the nurse should: 1. identify the client’s learning needs and advise the client on what to do. 2. provide pamphlets and videotapes for ongoing learning. 3. identify the client’s learning needs and learning ability. 4. identify the client’s problems and make the appropriate referral. Answer: 3 Rationale: 1. The nurse is discouraged from advising the client. Decisions are made with the client. 2. The client needs primary instruction on wound care before providing tools for ongoing learning. 3. As a teacher, the nurse first assesses the needs of the client and then determines the client’s ability to learn. 4. The nurse is responsible for determining the learning needs of the client. In some instances, such as wound care, a referral may be made to a wound care nurse. However, the nurse giving care is responsible for the initial determination of needs and abilities. Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Planning Learning Outcome: 1-3 9. The nurse is managing care for a client, and asks the nursing assistant to measure the client’s vital signs twice during the shift. The nurse is providing care by: 1. prioritizing. 2. delegating. 3. advocating. 4. teaching. Answer: 2 Rationale: 1. Prioritizing involves assessing and determining which care is needed first. 2. Delegating care is asking another member of the team who is qualified to perform client care. 3. Advocating is defending the client’s rights. 4. Teaching is the giving of needed information to a client. © 2016 by Pearson Education, Inc. Burke, Testgen for Medical-Surgical Nursing Care, 4 th Edition Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Implementation Learning Outcome: 1-3 10. After administering pain medication, the nurse returns to check the client’s level of comfort. In which stage is the nursing process functioning? 1. Assessment 2. Evaluation 3. Planning 4. Implementation Answer: 2 Rationale: 1. Assessment is done prior to giving pain medication to determine whether the medication is needed. 2. Evaluation is determining whether the treatment or medication was effective. 3. Planning is completed after assessment and is a determination of the nursing needs of the client. 4. Implementation would be administering the medication. Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Evaluation Learning Outcome: 1-4 11. The nurse is developing a nursing diagnosis for a client who has pneumonia. The nurse recognizes that the diagnosis describes an actual or potential problem that: 1. relates to the client’s primary diagnosis. 2. the nurse can treat independently. 3. the nurse can treat with a physician’s order. 4. requires a physician’s intervention. Answer: 2 Rationale: 1. The nurse develops a nursing diagnosis based on the client’s symptoms, not on the primary diagnosis. © 2016 by Pearson Education, Inc. Burke, Testgen for Medical-Surgical Nursing Care, 4 th Edition 2. A nursing diagnosis is based on implementations that nurses treat independently of the physician. 3. The physician does not need to write orders for nursing care. 4. A physician is not responsible for giving nursing care. Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Diagnosis Learning Outcome: 1-4 12. The client tells the nurse she has been smoking one pack of cigarettes a day for the past 20 years. The nurse recognizes that this is which part of the nursing process? 1. Evaluation 2. Planning 3. Assessment 4. Implementation Answer: 3 Rationale: 1. Evaluation is determining the effectiveness of care given. 2. Planning is determining the care needed after assessment. 3. Assessment includes data gathering and past history information. 4. Implementation involves the actual giving of care. Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome: 1-4 13. While hospitalized a client develops a new problem. Which behaviors should the nurse use to demonstrate critical thinking during this client’s assessment? (Select all that apply.) 1. Nursing habits 2. Clinical skills 3. Cognitive knowledge 4. Assumptions 5. Goal-directed thinking © 2016 by Pearson Education, Inc. Burke, Testgen for Medical-Surgical Nursing Care, 4 th Edition Answer: 2; 3; 5 Rationale: 1. Habits are actions done without much thought, and are usually routine. 2. The more clinical skills the nurse has, the better is the ability to think critically. Experience and skills help the nurse consider more options. 3. Cognitive knowledge is necessary in order to form an opinion or to process information. 4. Assumptions can lead to faulty conclusions because all information is not included in the process. 5. Goal-directed thinking allows the nurse to focus on the problem at hand and directs the investigation. Cognitive Level: Application Client Need: Physiological Integrity Nursing Process: Assessment Learning Outcome: 1-5