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Test Bank for Ackley and Ladwig's
Nursing Diagnosis Handbook, 13th
Edition: An Evidence-Based Guide to
Planning Care | Comprehensive
Exam Prep | Graded A+
Question 1
A nurse is formulating a nursing diagnosis for a client who has
impaired mobility. According to the three-step system used in Ackley
and Ladwig's Nursing Diagnosis Handbook, which of the following
represents the correct structure for a problem-focused nursing
diagnosis?
A. Diagnostic label related to defining characteristics as evidenced by
related factors
B. Problem (diagnostic label) related to etiology (related factors) as
evidenced by defining characteristics
C. Etiology related to problem as evidenced by defining characteristics
D. Defining characteristics related to problem as evidenced by etiology
Correct answer: B
Explanation: The correct PES format for a problem-focused nursing
diagnosis is Problem (diagnostic label) related to Etiology (related
factors) as evidenced by Defining characteristics (signs and
symptoms). This three-step system guides the nurse through client
assessment, nursing diagnosis, and care planning.
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Question 2
A nurse is reviewing the NANDA-I approved nursing diagnoses. Which
of the following statements accurately describes the purpose of a
nursing diagnosis?
A. To identify a medical disease process
B. To provide a standardized language for communicating client
problems
C. To replace the need for a medical diagnosis
D. To describe the client's response to a medical treatment
Correct answer: B
Explanation: A nursing diagnosis provides a standardized language for
communicating client problems and responses to health conditions. It
is distinct from a medical diagnosis, which identifies a disease process.
Nursing diagnoses describe client responses that nurses can
independently treat.
Question 3
A nurse is caring for a client who is postoperative and reports
incisional pain rated 7 on a scale of 0 to 10. The client is grimacing and
guarding the incision site. Which of the following is the most
appropriate nursing diagnosis?
A. Pain related to surgical incision as evidenced by client report of
7/10 pain and grimacing
B. Acute Pain related to surgical incision as evidenced by verbal report
of pain and guarding behavior
C. Impaired Physical Mobility related to pain as evidenced by guarding
behavior
D. Risk for Infection related to surgical incision as evidenced by pain
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and guarding
Correct answer: B
Explanation: "Acute Pain related to surgical incision as evidenced by
verbal report of pain and guarding behavior" follows the correct PES
format (Problem related to Etiology as evidenced by Defining
Characteristics). The diagnostic label "Acute Pain" is appropriate for
postoperative pain. The other options are either incorrectly formatted
or use inappropriate diagnostic labels.
Question 4
A nurse is developing a care plan for a client with a nursing diagnosis
of Ineffective Breathing Pattern. According to evidence-based practice
guidelines, which of the following interventions should the nurse
include?
A. Position the client in a supine position to promote lung expansion
B. Encourage the client to cough and deep breathe every 2 hours
C. Restrict fluid intake to reduce secretions
D. Administer oxygen at 4 L/min via nasal cannula
Correct answer: B
Explanation: Encouraging coughing and deep breathing every 2 hours
is an evidence-based intervention for Ineffective Breathing Pattern.
Supine positioning worsens breathing, fluid restriction is not
indicated, and oxygen flow rates should be based on prescription and
client need.
Question 5
A nurse is preparing to write a nursing diagnosis for a client who is at
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risk for falls. Which of the following is the correct format for a risk
nursing diagnosis?
A. Risk for Falls related to as evidenced by unsteady gait
B. Risk for Falls as evidenced by history of falls
C. Risk for Falls related to impaired mobility
D. Risk for Falls
Correct answer: C
Explanation: A risk nursing diagnosis is written as "Risk for [diagnostic
label] related to [risk factors]." The format is "Risk for Falls related to
impaired mobility." Risk diagnoses do not use "as evidenced by"
because defining characteristics are not yet present.
Question 6
A nurse is using the evidence-based guide in Ackley and Ladwig's
Nursing Diagnosis Handbook. Which of the following components is
included in the care plan for each nursing diagnosis?
A. Medical diagnosis and treatment plan
B. Expected outcomes and evidence-based interventions
C. Laboratory values and diagnostic tests
D. Pharmacological interventions only
Correct answer: B
Explanation: The handbook provides evidence-based interventions
with rationales and expected outcomes for each NANDA-I approved
nursing diagnosis. It does not focus on medical diagnoses, laboratory
values, or pharmacological interventions only.
Test Bank for Ackley and Ladwig's
Nursing Diagnosis Handbook, 13th
Edition: An Evidence-Based Guide to
Planning Care | Comprehensive
Exam Prep | Graded A+
Question 1
A nurse is formulating a nursing diagnosis for a client who has
impaired mobility. According to the three-step system used in Ackley
and Ladwig's Nursing Diagnosis Handbook, which of the following
represents the correct structure for a problem-focused nursing
diagnosis?
A. Diagnostic label related to defining characteristics as evidenced by
related factors
B. Problem (diagnostic label) related to etiology (related factors) as
evidenced by defining characteristics
C. Etiology related to problem as evidenced by defining characteristics
D. Defining characteristics related to problem as evidenced by etiology
Correct answer: B
Explanation: The correct PES format for a problem-focused nursing
diagnosis is Problem (diagnostic label) related to Etiology (related
factors) as evidenced by Defining characteristics (signs and
symptoms). This three-step system guides the nurse through client
assessment, nursing diagnosis, and care planning.
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Question 2
A nurse is reviewing the NANDA-I approved nursing diagnoses. Which
of the following statements accurately describes the purpose of a
nursing diagnosis?
A. To identify a medical disease process
B. To provide a standardized language for communicating client
problems
C. To replace the need for a medical diagnosis
D. To describe the client's response to a medical treatment
Correct answer: B
Explanation: A nursing diagnosis provides a standardized language for
communicating client problems and responses to health conditions. It
is distinct from a medical diagnosis, which identifies a disease process.
Nursing diagnoses describe client responses that nurses can
independently treat.
Question 3
A nurse is caring for a client who is postoperative and reports
incisional pain rated 7 on a scale of 0 to 10. The client is grimacing and
guarding the incision site. Which of the following is the most
appropriate nursing diagnosis?
A. Pain related to surgical incision as evidenced by client report of
7/10 pain and grimacing
B. Acute Pain related to surgical incision as evidenced by verbal report
of pain and guarding behavior
C. Impaired Physical Mobility related to pain as evidenced by guarding
behavior
D. Risk for Infection related to surgical incision as evidenced by pain
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and guarding
Correct answer: B
Explanation: "Acute Pain related to surgical incision as evidenced by
verbal report of pain and guarding behavior" follows the correct PES
format (Problem related to Etiology as evidenced by Defining
Characteristics). The diagnostic label "Acute Pain" is appropriate for
postoperative pain. The other options are either incorrectly formatted
or use inappropriate diagnostic labels.
Question 4
A nurse is developing a care plan for a client with a nursing diagnosis
of Ineffective Breathing Pattern. According to evidence-based practice
guidelines, which of the following interventions should the nurse
include?
A. Position the client in a supine position to promote lung expansion
B. Encourage the client to cough and deep breathe every 2 hours
C. Restrict fluid intake to reduce secretions
D. Administer oxygen at 4 L/min via nasal cannula
Correct answer: B
Explanation: Encouraging coughing and deep breathing every 2 hours
is an evidence-based intervention for Ineffective Breathing Pattern.
Supine positioning worsens breathing, fluid restriction is not
indicated, and oxygen flow rates should be based on prescription and
client need.
Question 5
A nurse is preparing to write a nursing diagnosis for a client who is at
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risk for falls. Which of the following is the correct format for a risk
nursing diagnosis?
A. Risk for Falls related to as evidenced by unsteady gait
B. Risk for Falls as evidenced by history of falls
C. Risk for Falls related to impaired mobility
D. Risk for Falls
Correct answer: C
Explanation: A risk nursing diagnosis is written as "Risk for [diagnostic
label] related to [risk factors]." The format is "Risk for Falls related to
impaired mobility." Risk diagnoses do not use "as evidenced by"
because defining characteristics are not yet present.
Question 6
A nurse is using the evidence-based guide in Ackley and Ladwig's
Nursing Diagnosis Handbook. Which of the following components is
included in the care plan for each nursing diagnosis?
A. Medical diagnosis and treatment plan
B. Expected outcomes and evidence-based interventions
C. Laboratory values and diagnostic tests
D. Pharmacological interventions only
Correct answer: B
Explanation: The handbook provides evidence-based interventions
with rationales and expected outcomes for each NANDA-I approved
nursing diagnosis. It does not focus on medical diagnoses, laboratory
values, or pharmacological interventions only.
