Test Bank for Medical-Surgical Nursing in Canada, 4th Edition

Name: Test Bank for Medical-Surgical Nursing in Canada, 4th Edition
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Test Bank for Medical-Surgical Nursing in Canada, 4th Edition provides an extensive collection of questions to test your knowledge.

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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 explains the nurses’ primary use of the nursing process when
providing care to clients?
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.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation
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.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
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.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
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 for this client?
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.
DIF: Cognitive Level: Application TOP: Nursing Process: Diagnosis
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 Level: Application TOP: Nursing Process: Planning
7. Which of the following represents a nursing activity that is carried out during the
evaluation phase of the nursing process?
a. Determining if interventions have been effective in meeting client outcomes
b. Documenting the nursing care plan in the progress notes in the medical record
c. Deciding whether the client’s health problems have been completely resolved
d. Asking the client to evaluate whether the nursing care provided was satisfactory
ANS: A
Evaluation consists of determining whether the desired client outcomes have been met and
whether the nursing interventions were appropriate. The other responses do not describe
the evaluation phase.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Evaluation
8. Which of the following would the nurse perform during the assessment phase of the
nursing process?
a. Obtains data with which to diagnose client problems
b. Uses client data to develop priority nursing diagnoses
c. Teaches interventions to relieve client health problems
d. Assists the client to identify realistic outcomes to health problems
ANS: A
During the assessment phase, the nurse gathers information about the client. The other
responses are examples of the intervention, diagnosis, and planning phases of the nursing
process.
DIF: Cognitive Level: Knowledge TOP: Nursing Process: Assessment
9. Which of the following is an example of a correctly written nursing diagnosis statement?
a. Altered tissue perfusion related to heart failure
b. Risk for impaired tissue integrity related to sacral redness
c. Ineffective coping related to insufficient sense of control.
d. Altered urinary elimination related to urinary tract infection
ANS: C
This diagnosis statement includes a NANDA nursing diagnosis and an etiology that
describes a client’s response to a health problem that can be treated by nursing. The use of
a medical diagnosis (as in the responses beginning “Altered tissue perfusion” and “Altered
urinary elimination”) is not appropriate. The response beginning “Risk for impaired tissue
integrity” uses the defining characteristics as the etiology.

DIF: Cognitive Level: Comprehension TOP: Nursing Process: Diagnosis
10. Which of the following includes the components required for a complete nursing diagnosis
statement?
a. A problem and the suggested client goals or outcomes
b. A problem, its cause, and objective data that support the problem
c. A problem with all its possible causes and the planned interventions
d. A problem with its etiology and the signs and symptoms of the problem
ANS: D
The PES format is used when writing nursing diagnoses. The subjective, as well as
objective, data should be included in the defining characteristics. Interventions and
outcomes are not included in the nursing diagnosis statement.
DIF: Cognitive Level: Knowledge TOP: Nursing Process: Diagnosis
11. Which of the following refers to a situation that results in unintended harm to the client
and is related to the care or services provided rather than the client’s medical condition?
a. Negligence
b. Adverse event
c. Incident report
d. Nonmaleficence
ANS: B
An adverse event is an event that results in unintended harm to the client and is related to
the care or services provided to the client rather than to the client’s underlying medical
condition.
DIF: Cognitive Level: Knowledge TOP: Nursing Process: Evaluation
12. When using the Five Steps of the evidence-informed practice (EIP) Process, which of the
flowing elements is the final step when constructing a clinical question?
a. Comparison of interest
b. Population of interest
c. Outcome of interest
d. Timeframe of interest
ANS: D
The order of the nurse’s statements follows the PICOT format with the final step being the
“T”, or timeframe of interest.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation

Chapter 02: Cultural Competence and Health Equity in Nursing Care
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. Which of the following terms refers to characteristics of a group whose members share a
common social, cultural, linguistic, or religious heritage?
a. Diversity
b. Ethnicity
c. Ethnocentrism
d. Cultural imposition
ANS: B
Ethnicity is the common social, cultural, linguistic, or religious heritage of a group of
people. Diversity is a presence of persons with differences from the majority or dominant
group that is assumed to be the norm. Ethnocentrism is a tendency of individuals to
believe that their way of viewing and responding to the world is the most correct, natural,
and superior one. Cultural imposition is imposition of one person's own cultural beliefs
and practices, intentionally or unintentionally, on another person or group of people.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning
2. The nurse is caring for Indigenous clients in a community clinic setting. Which of the
following would the nurse include when developing strategies to decrease health care
disparities?
a. Improve public transportation.
b. Obtain low-cost medications.
c. Update equipment and supplies for the clinic.
d. Educate staff about Indigenous health beliefs.
ANS: D
Health care disparities are due to stereotyping, biases, and prejudice of health care
providers; the nurse can decrease these through staff education. The other strategies also
may be addressed by the nurse but will not impact health disparities.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
3. A family member of an elderly Hispanic client admitted to the hospital tells the nurse that
the client has traditional beliefs about health and illness. Which of the following actions is
most appropriate for the nurse in this situation?
a. Avoid asking any questions unless the client initiates conversation.
b. Ask the client whether it is important that cultural healers are contacted.
c. Explain the usual hospital routines for meal times, care, and family visits.
d. Obtain further information about the client’s cultural beliefs from the daughter.
ANS: B

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Because the client has traditional health care beliefs, it is appropriate for the nurse to ask
whether the client would like a visit from a cultural healer. Nurses ask key questions with
regard to language, diet, religion, and acculturation and eliciting the client’s explanatory
model of health and illness. There is no cultural reason for the nurse to avoid asking the
client questions, and questions may be necessary to obtain necessary health information.
The client (rather than the daughter) should be consulted about personal cultural beliefs.
The hospital routines for meals, care, and visits should be adapted to the client’s
preferences rather than expecting the client to adapt to the hospital schedule.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
4. When caring for an Indigenous client, which of the following actions is the best initial
approach in relation to eye contact for the nurse to take?
a. Avoid all eye contact with the client.
b. Observe the client’s use of eye contact.
c. Look directly at the client when interacting.
d. Ask the family about the client’s cultural beliefs.
ANS: B
Eye contact varies greatly among and within cultures so the nurses’ initial action is to
assess the client’s use of eye contact. Although nurses are often taught to maintain direct
eye contact, clients who are Asian, Arab, or Indigenous may avoid direct eye contact and
consider direct eye contact disrespectful or aggressive. Looking directly at the client or
avoiding eye contact may be appropriate, depending on the client’s individual cultural
beliefs. The nurse should assess the client, rather than asking family members about the
client’s beliefs.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
5. A graduate nurse is assessing a newly admitted non–English-speaking Chinese client who
complains of severe headaches. Which of the following actions by the graduate nurse
would cause the charge nurse to intervene during this assessment interview?
a. Sit down at the bedside.
b. Palpate the client’s scalp.
c. Call for a medical interpreter.
d. Avoid eye contact with the client.
ANS: B
Many people of Asian ethnicity believe that touching a person’s head is disrespectful; the
nurse should always ask permission before touching any client’s head. The other actions
are appropriate.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
6. The nurse is caring for a client who speaks a language different from the nurse’s language
and there is no interpreter available. Which of the following actions is the most
appropriate for the nurse to implement?
a. Use specific medical terms in the Latin form.
b. Talk loudly and slowly so that each word is clearly heard.
c. Repeat important words so that the client recognizes their importance.
d. Use simple gestures to demonstrate meaning while talking to the client.

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ANS: D
The use of gestures will enable some information to be communicated to the client. The
other actions will not improve communication with the client.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation
7. According to the ABC(DE)s of cultural competence, awareness of and sensitivity to
cultural values is in which of the following domains?
a. Skills domain
b. Affective domain
c. Knowledge domain
d. Behavioural domain
ANS: B
The affective domain reflects an awareness of and sensitivity to cultural values, needs, and
biases. The skills domain does not reflect an awareness of and sensitivity to cultural values,
needs, and biases. There is no skills or knowledge domain; with ABC(DE) it is affective,
behavioural, and cognitive domains as well as dynamics of difference and environment.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning
8. Which of the following actions represents the best example of culturally appropriate
nursing care when caring for a newly admitted client?
a. Have family members provide most of the client’s personal care.
b. Maintain a personal space of at least 0.5 m when assessing the client.
c. Ask permission before touching a client during the physical assessment.
d. Consider the client’s ethnicity as the most important factor in planning care.
ANS: C
Many cultures consider it disrespectful to touch a client without asking permission, so
asking a client for permission is always culturally appropriate. The other actions may be
appropriate for some clients but are not appropriate across all cultural groups or for all
individual clients.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Implementation
9. While talking with the nursing supervisor, a staff nurse expresses frustration that an
Indigenous client always has several family members at the bedside. Which of the
following actions is the most appropriate action for the nursing supervisor in this
situation?
a. Remind the nurse that family support is important to this family and client.
b. Have the nurse explain to the family that too many visitors will tire the client.
c. Suggest that the nurse ask family members to leave the room during client care.
d. Ask about the nurse’s personal beliefs about family support during hospitalization.
ANS: D

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The first step in providing culturally competent care is to understand one’s own beliefs and
values related to health and health care. Asking the nurse about personal beliefs will help
to achieve this step. Reminding the nurse that this cultural practice is important to the
family and client will not decrease the nurse’s frustration. The remaining responses
(suggest that the nurse ask family members to leave the room, and have the nurse explain
to family that too many visitors will tire the client) are not culturally appropriate for this
client.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
10. An elderly Asian Canadian client tells the nurse that she has lived in Canada for 50 years.
The client speaks English but lives in a predominantly Asian neighbourhood. Which of the
following actions is most appropriate for the nurse?
a. Arrange to have a folk healer available when planning the client’s care.
b. Ask the client about any special cultural beliefs or practices.
c. Avoid making direct eye contact with the client during care.
d. Involve the client’s oldest son in making health care decisions.
ANS: B
Further assessment of the client’s health care preferences is needed before making further
plans for culturally appropriate care. The other responses indicate stereotyping of the
client, based on ethnicity, and would not be appropriate initial actions.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
11. Which of the following statements is true related to immigrants to Canada?
a. Decreased risk of social exclusion related to Canada’s multicultural population.
b. New immigrants tend to be in overall better health than the resident population.
c. Health status of immigrants is not related to length of time in Canada.
d. Unemployment is not associated with poorer health outcomes for immigrants.
ANS: B
The healthy immigrant effect indicates that new immigrants tend to be in better overall
health than the general resident population. This finding is not surprising inasmuch as
immigrants are screened before being granted admittance to Canada. Health status is
related to length of time in Canada, the health of immigrants, 20 years after immigration,
as determined by age-standardized mortality rates, is generally poorer than those of the
Canadian-born population. Underemployment, unemployment, and workplace stress place
immigrants at increased health risks as well as the risk for social exclusion.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning
12. Which of the following question formats is the most appropriate for the nurse to ask when
communicating with a client that has limited English proficiency?
a. Are you tired and in discomfort?
b. You have taken your pills right?
c. Are you alright?
d. Are you in pain?
ANS: D

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When communicating with a client that has limited English proficiency, the best questions
to ask are ones that are in simple language a couple of words, plain simple terms, such as
“Are you in pain?” Asking about tiredness and discomfort in the same sentence should be
avoided—ask one item at a time and use the term ‘pain’, not discomfort. Asking the client
“are you alright” is vague and will elicit a yes or no answer. “You have taken your pills
right?” is accusatory and should be avoided.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
13. An Indigenous client tells the nurse that he thinks his abdominal pain is caused by eating
too much seal fat and that strong massage over the stomach will help it. Which of the
following statements depicts what the client is describing to the nurse?
a. Evidence-informed national guidelines
b. Awareness and knowledge of his own culture
c. The explanatory model of health and health practices
d. Knowledge about the difference in modern and folk health practices
ANS: C
The explanatory model is a set of beliefs regarding what causes the disease or illness and
the methods that would potentially treat the condition best. Different cultural groups have
different beliefs about the causes of illness and the appropriateness of various treatments.
The situation is not reflective of national guidelines. There is no comparison between
modern and folk health practices. The client is explaining experiences and beliefs’ rather
than awareness and knowledge.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
14. Which of the following statements represents a health inequity currently experienced in
Canada?
a. Indigenous adults are less likely to smoke tobacco than other adults in Canada.
b. Overall suicide rate among First Nation communities is about twice the rate of the
general population.
c. Individuals from lower income neighbourhoods undergo preventive health
screening more that their higher income counterparts.
d. Recent immigrants are more likely to have a primary care physician than
Canadian-born individuals.
ANS: B
Suicide rates are five to seven times higher among Indigenous youth than among
non-Indigenous youth. Suicide rates among Indigenous youth are among the highest in the
world, at 11 times the national average. Smoking rates are more than two times higher
among the three Indigenous groups than among the non-Indigenous population.
Individuals from higher income neighbourhoods undergo preventive health screening
more than those from lower income neighbourhoods. Recent immigrants are less likely to
have a primary care physician than Canadian-born individuals.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment
15. When performing a cultural assessment with a client of a different culture, which of the
following actions is the initial action to be taken by the nurse?
a. Wait until a cultural healer is available to help with the assessment.

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b. Obtain a list of any cultural remedies that the client currently uses.
c. Ask the client about any affiliation with a particular cultural group.
d. Tell the client what the nurse already knows about the client’s culture.
ANS: C
An early step in performing a cultural assessment is to determine the cultural group with
which the client identifies. The other actions may be appropriate if the client does identify
with a particular culture.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
16. Equity in health care is concerned with creating equal opportunities for good health for
everyone in which one of the following ways?
a. Increase negative effect of social determinants of health.
b. Increase awareness of acute care programs.
c. Decrease non-modifiable risk factors.
d. Reduce exclusion.
ANS: D
Health equity is concerned with creating equal opportunities for good health for everyone
in two ways: (a) decreasing the negative effect of the social determinants of health and (b)
by improving services to enhance access and reduce exclusion.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment

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Chapter 03: Health History and Physical Examination
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. An older-adult client who is having difficulty breathing is admitted to the hospital. Which
of the following approaches is the best for the nurse to use to obtain a complete health
history?
a. Obtain subjective data about the client from family members.
b. Omit subjective data collection and obtain the physical examination.
c. Use the health care provider’s medical history to obtain subjective data.
d. Schedule several short sessions with the client to gather subjective data.
ANS: D
In the case of an older-adult client with a low energy level, several short sessions may
have to be scheduled. Allowing time for the client to volunteer information about
particular areas of concern enables the nurse to work with the client to identify existing
and potential health problems. In an emergency situation, the nurse may need to ask only
the most pertinent questions for a specific problem and obtain more information later. A
complete health history will include subjective information that is not available in the
health care provider’s medical history. Family members may be able to provide some
subjective data, but only the client will be able to give subjective information about the
shortness of breath. Since the subjective data about the client’s respiratory status will be
essential, obtaining the physical examination alone will not provide sufficient information.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
2. Immediate surgery is planned for a client with acute abdominal pain. Which of the
following questions will elicit the most complete information about the client’s
coping-stress tolerance pattern?
a. “Can you tell me how intense your pain is now?”
b. “What do you think caused this abdominal pain?”
c. “How do you feel about yourself and your hospitalization?”
d. “Are there other major problems that are a concern right now?”
ANS: D
The coping-stress tolerance pattern includes information about other major stressors
confronting the client. The health perception–health management pattern includes
information about the client’s ideas about risk factors. Feelings about self and the
hospitalization are assessed in the self-perception–self-concept pattern. Intensity of pain is
part of the cognitive–perceptual pattern.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment
3. During the health history interview, a client tells the nurse about periodic fainting spells.
Which question by the nurse will be most helpful in determining the setting in which the
fainting spells occur?
a. “How frequently do you have the fainting spells?”
b. “Where are you when you have the fainting spells?”
c. “Do the spells tend to occur at any special time of day?”

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d. “Do you have any other symptoms along with the spells?”
ANS: B
Information about the setting is obtained by asking where the client was and what the
client was doing when the symptom occurred. The other questions from the nurse are
appropriate for obtaining information about chronology, frequency, and associated clinical
manifestations.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment
4. The nurse records the following general survey of a client: “The client is a 68-year-old
male Asian accompanied by his wife and two daughters. Alert and oriented. Does not
make eye contact with the nurse and responds slowly, but appropriately, to questions. No
apparent disabilities or distinguishing features.” Which of the following information
should be added to this general survey documentation?
a. Nutritional status
b. Intake and output
c. Reasons for contact with the health care system
d. Comments of family members about his condition
ANS: A
The general survey also describes the client’s general nutritional status. The other
information will be obtained when doing the complete nursing history and examination but
is not obtained through the initial scanning of a client.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
5. A nurse is performing a health history and physical examination for a client with
right-sided rib fractures. Which of the following data is a pertinent negative finding?
a. Client states that there have been no other health problems recently.
b. Client denies having pain when the area over the fractures is palpated.
c. Client has several bruised and swollen areas on the right anterior chest.
d. Client refuses to take a deep breath because of the associated chest pain.
ANS: B
The nurse expects that a client with rib fractures will have pain over the fractured area.
The first statement is neither a positive nor a negative finding with regard to the rib
fractures. The bruising and swelling and pain with breathing are positive findings.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
6. As the nurse assesses the client’s neck, the client says, “My neck is so stiff I can hardly
move it.” This client statement indicates the nurse should perform which of the following
assessments?
a. Focused
b. Screening
c. Emergency
d. Comprehensive
ANS: A

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The focused assessment is needed when a client has clinical manifestations that indicate a
problem. An emergency assessment is done when the nurse needs to obtain information
about life-threatening problems quickly while simultaneously taking action to maintain
vital function. The screening assessment is not recognized as one of the three main types
of assessment. A comprehensive assessment is a detailed health history and physical
examination.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
7. The nurse is preparing to perform a focused abdominal assessment for a client who has
high-pitched bowel sounds. Which equipment will be needed?
a. Flashlight
b. Stethoscope
c. Tongue blades
d. Percussion hammer
ANS: B
A stethoscope is used to auscultate bowel sounds. The other equipment may be used for a
comprehensive assessment, but will not be needed for a focused abdominal assessment.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment
8. When the nurse is planning for the physical examination of an alert older-adult client,
which of the following adaptations to the examination technique should be considered?
a. Speaking slowly when directing the client
b. Avoiding the use of touch as much as possible
c. Using slightly more pressure for palpation of the liver
d. Organizing the sequence to minimize position changes
ANS: D
Older clients may have age-related changes in mobility that make it more difficult to
change position. There is no need to avoid the use of touch when examining older clients.
Less pressure should be used over the liver. Since the client is alert, there is no indication
that there is any age-related difficulty in understanding directions from the nurse.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
9. While the nurse is taking the health history, a client states, “My father and grandfather
both had heart attacks and were unable to be very active afterwards.” This statement
reflects which of the following functional health patterns?
a. Activity—exercise
b. Cognitive—perceptual
c. Coping—stress tolerance
d. Health perception—health management
ANS: D
The information in the client statement relates to risk factors that may cause
cardiovascular problems in the future. Identification of risk factors falls into the health
perception—health maintenance pattern.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment

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ANS: D
When assessing the abdomen, auscultation is done before palpation or percussion because
palpation and percussion can cause changes in bowel sounds and alter the findings. All of
the techniques are appropriate, but auscultation should be done first.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment
14. When admitting a client who has just arrived on the medical unit with severe abdominal
pain, what should the nurse do first?
a. Complete only basic demographic data before addressing the client’s abdominal
pain.
b. Medicate the client for the abdominal pain before attending to the health history
and examination.
c. Inform the client that the abdominal pain will be treated as soon as the health
history is completed.
d. Take the initial vital signs and then deal with the abdominal pain before
completing the health history.
ANS: D
The client priority in this situation will be to decrease the pain level because the client will
be unlikely to cooperate in providing demographic data or the health history until the nurse
addresses the pain. However, obtaining information about vital signs is essential before
using either pharmacological or nonpharmacological therapies for pain control. The vital
signs may indicate hemodynamic instability that would need to be addressed immediately.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
15. The nurse is completing a neurological assessment on an adult client. The nurse should
implement which one of the following assessments when assessing the client’s motor
status?
a. Toe walk
b. Finger to nose
c. Romberg
d. Heel to opposite shin
ANS: A
A neurological assessment is completed to observe motor status by assessing gait, toe and
heel walk, and drift whereas when assessing coordination, the nurses observes finger to
nose, Romberg sign and heel to opposite shin.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment

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Chapter 04: Patient and Caregiver Teaching
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. A client with newly diagnosed breast cancer has a nursing diagnosis of deficient
knowledge related to insufficient information (about breast cancer). When the nurse is
planning teaching for the client, which is the most important initial learning goal?
a. The client will select the most appropriate breast cancer therapy.
b. The client will state ways of preventing the recurrence of the tumour.
c. The client will demonstrate coping skills needed to manage the disease.
d. The client will choose methods to minimize adverse effects of treatment.
ANS: A
Adults learn best when given information that can be used immediately. The first action
the client will need to take after a cancer diagnosis is to choose a treatment option. The
other goals may be appropriate as treatment progresses.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
2. After the nurse implements diet instruction for a client with heart disease, the client can
explain the information but fails to make the recommended dietary changes. Which of the
following statements reflects the correct evaluation of the intervention?
a. Learning did not occur because the client’s behaviour did not change.
b. Choosing not to follow the diet is the behaviour that resulted from learning.
c. The nursing responsibility for helping the client make dietary changes has been
fulfilled.
d. The teaching methods were ineffective in helping the client learn the dietary
information.
ANS: B
Although the client behaviour has not changed, the client’s ability to explain the
information indicates that learning has occurred and the client is choosing at this time to
continue with the previous diet. The client may be in the contemplation or preparation
state in the Transtheoretical Model. The nurse should reinforce the need for change and
continue to provide information and assistance with planning for change.
DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation
3. The nurse is caring for an adult client who has been diagnosed with type 2 diabetes
mellitus after being admitted to the hospital with an infected foot wound. When applying
principles of adult learning, which teaching strategy by the nurse is most likely to be
effective?
a. Discuss the importance of blood glucose control in maintenance of long-term
health.
b. Demonstrate the correct method for cleaning and redressing the wound to the
client.
c. Assure the client that the nurse is an expert on management of diabetes
complications.
d. Wait until after discharge and have a home health nurse teach about foot care and

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diabetes management.
ANS: B
Principles of adult education indicate that readiness and motivation to learn are high when
facing new tasks (such as wound care) and when demonstration and practice of skills are
available. Although a home health referral may be needed for this client, teaching should
not be postponed until discharge. Adult learners are independent; the nurse should act as a
facilitator for learning, rather than as the expert. Adults learn best when the topic is of
immediate usefulness; long-term goals may not be very motivating.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
4. A client admitted to the hospital with hyperglycemia and newly diagnosed diabetes
mellitus is scheduled for discharge the second day after admission. When implementing
client teaching, which is the best action for the nurse to take?
a. Instruct about the increased risk for cardiovascular disease.
b. Provide detailed information about dietary control of glucose.
c. Teach glucose self-monitoring and medication administration.
d. Give information about the effects of exercise on glucose control.
ANS: C
When time is limited, the nurse should focus on the priorities of teaching. In this situation,
the client should know how to test blood glucose and administer medications to control
glucose levels. The client will need further teaching about the role of diet, exercise,
various medications, and the many potential complications of diabetes, but these topics
can be addressed through planning for appropriate referrals.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
5. When using the Transtheoretical Model of Health Behaviour Change during client
teaching, the nurse identifies that the client who states, “I told my wife that I was going to
start exercising, and I think I will join a fitness club,” is in which of the following stages?
a. Preparation
b. Termination
c. Maintenance
d. Contemplation
ANS: A
The client’s statement indicating that the plan for change is being shared with someone
else indicates that the preparation stage has been achieved. Contemplation of a change
would be indicated by a statement like “I know I should exercise.” Maintenance of a
change occurs when the client practices the behaviour regularly. Termination would be
indicated when the change is a permanent part of the lifestyle.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment
6. While admitting a client to the medical unit, the nurse learns that the client has difficulty
reading. This information will guide the nurse in determining which of the following
strategies would be the most appropriate when planning for client teaching?
a. Assessing the degree of client motivation and readiness to learn
b. Deciding what information the client will be able to understand

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c. Ensuring that the family be included in the teaching process
d. Choosing which instructional strategies should be used in teaching
ANS: D
The information that the client has poor health literacy skills indicates that the nurse
should avoid the use of written materials in teaching and choose other strategies. The
client does not indicate a lack of motivation or an inability to understand new information.
The client’s lack of reading ability does not necessarily imply that the family must be
included in the teaching process.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning
7. When assessing the learning needs for a client who has coronary heart disease, the nurse
finds that the client has recently made dietary changes to decrease fat intake and has
stopped smoking. Which of the following is the most appropriate initial statement by the
nurse at this time?
a. “Although those are important, it is essential that you make other changes, too.”
b. “Are you having any difficulty in maintaining the changes you have already
made?”
c. “You have already accomplished some changes that are important in heart health.”
d. “Which additional changes in your lifestyle would you like to implement at this
time?”
ANS: C
Positive reinforcement of the learner’s achievements is critical in making lifestyle changes.
This client is in the action stage of the Transtheoretical Model, when reinforcement of the
changes being made is an important nursing intervention. The other responses are also
appropriate, but are not the best initial response.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
8. When assessing a client’s readiness to learn before planning teaching activities, which
question should the nurse ask?
a. “What kind of work and leisure activities do you do?”
b. “What information do you think you need right now?”
c. “Do you have any religious beliefs that are inconsistent with the treatment?”
d. “Can you describe the types of activities that help you learn new information?”
ANS: B
Motivation and readiness to learn depend on what the client values and perceives as
important. The other questions are also important in developing the teaching plan, but do
not address what information most interests the client at present.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
9. The nurse is caring for a client with diabetes and develops a nursing diagnosis of
ineffective health management related to insufficient knowledge of therapeutic regimen
(resulting in low motivation). Which of the following client actions is the basis for this
nursing diagnosis?
a. Does not perform capillary blood glucose tests as directed
b. Occasionally forgets to take the daily prescribed medication

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c. Says that dietary intake does not seem to impact fatigue level
d. Cannot identify signs or symptoms of high and low blood glucose
ANS: C
The client’s motivation to follow a diabetic diet will be decreased if the client feels that
dietary changes do not impact symptoms. The other responses do not indicate that the
ineffective health maintenance is caused by lack of motivation.
DIF: Cognitive Level: Application TOP: Nursing Process: Diagnosis
10. A client with poor circulation to the feet requires teaching about foot care. Which learning
goal should the nurse include in the teaching plan?
a. The nurse will demonstrate the proper technique for trimming toenails.
b. The client will list three ways to protect the feet from injury by discharge.
c. The nurse will instruct the client on appropriate foot care before discharge.
d. The client will understand the rationale for proper foot care after instruction.
ANS: B
Learning goals should state clear, measurable outcomes of what is to be accomplished
from the learning process. Demonstrating a proper technique or providing instruction are
actions that the nurse will take, rather than behaviours that would indicate if client learning
has occurred. Having the client understand the rational for proper foot care after
instruction is an example of a learning outcome.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
11. The nurse is planning a teaching session for a client who needs to improve skills in being
more assertive. Which of the following is the most effective teaching strategy for this
client?
a. Role-playing
b. Peer teaching
c. Printed materials
d. Lecture-discussion
ANS: A
Role playing allows the client to practice assertive behaviour and receive feedback about
how the behaviour is perceived. This strategy is most often used when clients need to
examine their attitudes and behaviours; understand the viewpoints and attitudes of others;
or practise carrying out thoughts, ideas, or decisions. Lecture-discussion, peer teaching,
and printed materials are more useful for other learning needs.
DIF: Cognitive Level: Comprehension TOP: Nursing Process: Planning
12. The client’s teaching plan includes this goal: “The client will select a 2-g sodium diet from
the hospital menu for the next 3 days.” Which evaluation method will be best for the nurse
to use when determining whether teaching was effective?
a. Check the sodium content of the client’s menu choices over the next 3 days.
b. Ask the client to identify which foods on the hospital menus are high in sodium.
c. Have the client list favourite foods that are high in sodium and foods that could be
substituted for these favourites.
d. Compare the client’s sodium intake over the next 3 days with the sodium intake

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before the teaching was implemented.
ANS: A
All of the answers address the client’s sodium intake, but the desired client behaviours in
the learning objective are most clearly addressed by evaluation of the client’s menu
choices.
DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation
13. The nurse is preparing written handouts to be used as part of the standardized teaching
plan for clients who have been recently diagnosed with diabetes and requires an awareness
of literacy levels. Which of the following literacy levels is generally reflective of students
who graduate from high school?
a. 1
b. 2
c. 3
d. 4
ANS: C
People with Level 3 literacy have the minimum skills necessary for everyday life in a
complex society, such as graduation from high school. People with Level 1 literacy have
very poor skills; for example, they were unable to determine the correct dose of
medication from information on the package. People with Level 2 literacy require material
to be simple and clearly laid out, and only tasks that are not too complex are to be included
in learning material. People at this level could read but had poor test results. People with
Levels 4 and 5 literacy had higher-order skills in information processing.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
14. The nurse in the hospital has implemented a teaching plan to assist a client with
rheumatoid arthritis in accomplishing daily activities independently. Which of the
following actions is the best approach for the nurse to take in order to evaluate the client’s
long-term response to the teaching?
a. Make a referral to the home health nursing department for home visits.
b. Assess the client’s ability to bathe without any assistance the next day.
c. Have the client demonstrate the learned skills at the end of the teaching session.
d. Arrange a physical therapy visit before the client is discharged from the hospital.
ANS: A
The client’s long-term response may need to be assessed after discharge; long-term
evaluation necessitates follow-up by the nurse, outpatient clinic, or outside agency. In this
case, a home health referral would allow this to occur. The other actions allow evaluation
of the client’s short-term response to teaching.
DIF: Cognitive Level: Application TOP: Nursing Process: Evaluation
15. A young adult client tells the nurse, “I enjoy smoking and have no plans to quit.” Which
stage of the Transtheoretical Model of Health Behaviour Change does this example
portray?
a. Contemplation
b. Precontemplation

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Test Bank for Medical-Surgical Nursing in Canada, 4th Edition

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