Test Bank For Ackley and Ladwig's Nursing
Diagnosis Handbook 13th Edition- An
Evidence-Based Guide to Planning Care
by |Mary |Beth |Flynn |Makic
@2024
,Section I: Nursing Diagnosis, the Nursing Process, and Evidence- Based
| | | | | | | | |
Nursing
|
1. What is the primary goal of a nursing diagnosis?
| | | | | | | |
a. To identify a medical diagnosis
| | | | |
b. To determine the effectiveness of medications
| | | | | |
c. To identify patient problems that can be managed by nursing
| | | | | | | | | |
interventions
|
d. To prioritize physician orders
| | | |
ANS: C |
Rationale: The primary goal of a nursing diagnosis is to identify patient problems
| | | | | | | | | | | |
that can be managed by nursing interventions, focusing on patient care rather than
| | | | | | | | | | | | |
medical diagnoses.
| |
NCLEX Preference: Understanding the distinction between nursing and medical
| | | | | | | |
diagnoses is crucial for patient-centered care.
| | | | | |
2. Which component of the nursing diagnosis indicates the problem?
| | | | | | | |
a. Defining characteristics
| |
b. Related factors
| |
c. The actual diagnosis
| | |
d. The patient’s history
| | |
ANS: C |
Rationale: The actual diagnosis represents the problem identified in the nursing
| | | | | | | | | |
assessment. It is essential for formulating a care plan.
| | | | | | | | |
NCLEX Preference: Clear identification of nursing diagnoses is necessary for
| | | | | | | | |
effective care planning.
| | |
3. What does the "related to" (R/T) statement in a nursing diagnosis signify?
| | | | | | | | | | |
a. It identifies the patient's response to the problem
| | | | | | | |
b. It indicates the underlying cause of the problem
| | | | | | | |
c. It lists the symptoms observed
| | | | |
d. It describes the treatment plan
| | | | |
ANS: B |
Rationale: The "related to" (R/T) statement indicates the underlying cause or
| | | | | | | | | |
contributing factors of the patient’s problem, guiding intervention strategies.
| | | | | | | | |
,NCLEX Preference: Understanding etiology is vital for targeted nursing
| | | | | | | |
interventions.
|
4. Which nursing diagnosis format is used to articulate the problem clearly?
| | | | | | | | | |
a. Problem-focused diagnosis
| |
b. Risk diagnosis
| |
c. Health promotion diagnosis
| | |
d. All of the above
| | | |
ANS: D |
Rationale: All formats—problem-focused, risk, and health promotion—articulate
| | | | | |
different aspects of patient care and are important in various clinical situations.
| | | | | | | | | | | |
NCLEX Preference: Familiarity with different nursing diagnosis formats enhances
| | | | | | | |
clinical reasoning.
| |
5. In which phase of the nursing process is the nursing diagnosis formulated?
| | | | | | | | | | |
a. Assessment
|
b. Diagnosis
|
c. Planning
|
d. Implementation
|
ANS: B |
Rationale: The nursing diagnosis is formulated during the diagnosis phase, after
| | | | | | | | | |
collecting and analyzing assessment data.
| | | | |
NCLEX Preference: Understanding the nursing process phases is crucial for
| | | | | | | | |
effective care delivery.
| | |
6. What is a defining characteristic in a nursing diagnosis?
| | | | | | | |
a. The cause of the problem
| | | | |
b. The observable signs and symptoms
| | | | |
c. The expected outcomes
| | |
d. The patient's medical history
| | | |
ANS: B |
Rationale: Defining characteristics are the observable signs and symptoms that
| | | | | | | | |
validate the nursing diagnosis and provide evidence of the problem.
| | | | | | | | | |
NCLEX Preference: Identifying defining characteristics is essential for accurate
| | | | | | | |
diagnosis and planning.
| | |
, 7. How can a nurse validate a nursing diagnosis?
| | | | | | |
a. By relying solely on personal experience
| | | | | |
b. By collecting data from various sources, including the patient
| | | | | | | | |
c. By discussing it only with physicians
| | | | | |
d. By documenting the diagnosis without evidence
| | | | | |
ANS: B |
Rationale: Validating a nursing diagnosis involves collecting data from multiple
| | | | | | | | |
sources, including the patient, to ensure accuracy and relevance.
| | | | | | | | |
NCLEX Preference: Validation of nursing diagnoses is critical for patient safety
| | | | | | | | | |
and effective care.
| | |
8. What role does evidence-based practice play in nursing diagnoses?
| | | | | | | |
a. It complicates the diagnosis process
| | | | |
b. It provides a scientific basis for nursing decisions
| | | | | | | |
c. It is optional for nursing practice
| | | | | |
d. It focuses solely on traditional methods
| | | | | |
ANS: B |
Rationale: Evidence-based practice provides a scientific basis for nursing
| | | | | | | |
decisions, improving patient outcomes and ensuring care is effective and relevant.
| | | | | | | | | | |
NCLEX Preference: Knowledge of evidence-based practice is essential for
| | | | | | | | |
modern nursing.
| |
9. What is the purpose of the planning phase in the nursing process?
| | | | | | | | | | |
a. To assess the patient’s condition
| | | | |
b. To develop a care plan with measurable goals
| | | | | | | |
c. To implement interventions immediately
| | | |
**d. To evaluate patient outcomes | | | |
ANS: B |
Rationale: The planning phase involves developing a care plan with measurable
| | | | | | | | | |
goals and outcomes tailored to the patient’s needs.
| | | | | | | |
NCLEX Preference: Effective planning is key to successful patient outcomes.
| | | | | | | | |
10. How should nursing diagnoses be prioritized?
| | | | |
a. Based on the nurse’s preference
| | | | |
Diagnosis Handbook 13th Edition- An
Evidence-Based Guide to Planning Care
by |Mary |Beth |Flynn |Makic
@2024
,Section I: Nursing Diagnosis, the Nursing Process, and Evidence- Based
| | | | | | | | |
Nursing
|
1. What is the primary goal of a nursing diagnosis?
| | | | | | | |
a. To identify a medical diagnosis
| | | | |
b. To determine the effectiveness of medications
| | | | | |
c. To identify patient problems that can be managed by nursing
| | | | | | | | | |
interventions
|
d. To prioritize physician orders
| | | |
ANS: C |
Rationale: The primary goal of a nursing diagnosis is to identify patient problems
| | | | | | | | | | | |
that can be managed by nursing interventions, focusing on patient care rather than
| | | | | | | | | | | | |
medical diagnoses.
| |
NCLEX Preference: Understanding the distinction between nursing and medical
| | | | | | | |
diagnoses is crucial for patient-centered care.
| | | | | |
2. Which component of the nursing diagnosis indicates the problem?
| | | | | | | |
a. Defining characteristics
| |
b. Related factors
| |
c. The actual diagnosis
| | |
d. The patient’s history
| | |
ANS: C |
Rationale: The actual diagnosis represents the problem identified in the nursing
| | | | | | | | | |
assessment. It is essential for formulating a care plan.
| | | | | | | | |
NCLEX Preference: Clear identification of nursing diagnoses is necessary for
| | | | | | | | |
effective care planning.
| | |
3. What does the "related to" (R/T) statement in a nursing diagnosis signify?
| | | | | | | | | | |
a. It identifies the patient's response to the problem
| | | | | | | |
b. It indicates the underlying cause of the problem
| | | | | | | |
c. It lists the symptoms observed
| | | | |
d. It describes the treatment plan
| | | | |
ANS: B |
Rationale: The "related to" (R/T) statement indicates the underlying cause or
| | | | | | | | | |
contributing factors of the patient’s problem, guiding intervention strategies.
| | | | | | | | |
,NCLEX Preference: Understanding etiology is vital for targeted nursing
| | | | | | | |
interventions.
|
4. Which nursing diagnosis format is used to articulate the problem clearly?
| | | | | | | | | |
a. Problem-focused diagnosis
| |
b. Risk diagnosis
| |
c. Health promotion diagnosis
| | |
d. All of the above
| | | |
ANS: D |
Rationale: All formats—problem-focused, risk, and health promotion—articulate
| | | | | |
different aspects of patient care and are important in various clinical situations.
| | | | | | | | | | | |
NCLEX Preference: Familiarity with different nursing diagnosis formats enhances
| | | | | | | |
clinical reasoning.
| |
5. In which phase of the nursing process is the nursing diagnosis formulated?
| | | | | | | | | | |
a. Assessment
|
b. Diagnosis
|
c. Planning
|
d. Implementation
|
ANS: B |
Rationale: The nursing diagnosis is formulated during the diagnosis phase, after
| | | | | | | | | |
collecting and analyzing assessment data.
| | | | |
NCLEX Preference: Understanding the nursing process phases is crucial for
| | | | | | | | |
effective care delivery.
| | |
6. What is a defining characteristic in a nursing diagnosis?
| | | | | | | |
a. The cause of the problem
| | | | |
b. The observable signs and symptoms
| | | | |
c. The expected outcomes
| | |
d. The patient's medical history
| | | |
ANS: B |
Rationale: Defining characteristics are the observable signs and symptoms that
| | | | | | | | |
validate the nursing diagnosis and provide evidence of the problem.
| | | | | | | | | |
NCLEX Preference: Identifying defining characteristics is essential for accurate
| | | | | | | |
diagnosis and planning.
| | |
, 7. How can a nurse validate a nursing diagnosis?
| | | | | | |
a. By relying solely on personal experience
| | | | | |
b. By collecting data from various sources, including the patient
| | | | | | | | |
c. By discussing it only with physicians
| | | | | |
d. By documenting the diagnosis without evidence
| | | | | |
ANS: B |
Rationale: Validating a nursing diagnosis involves collecting data from multiple
| | | | | | | | |
sources, including the patient, to ensure accuracy and relevance.
| | | | | | | | |
NCLEX Preference: Validation of nursing diagnoses is critical for patient safety
| | | | | | | | | |
and effective care.
| | |
8. What role does evidence-based practice play in nursing diagnoses?
| | | | | | | |
a. It complicates the diagnosis process
| | | | |
b. It provides a scientific basis for nursing decisions
| | | | | | | |
c. It is optional for nursing practice
| | | | | |
d. It focuses solely on traditional methods
| | | | | |
ANS: B |
Rationale: Evidence-based practice provides a scientific basis for nursing
| | | | | | | |
decisions, improving patient outcomes and ensuring care is effective and relevant.
| | | | | | | | | | |
NCLEX Preference: Knowledge of evidence-based practice is essential for
| | | | | | | | |
modern nursing.
| |
9. What is the purpose of the planning phase in the nursing process?
| | | | | | | | | | |
a. To assess the patient’s condition
| | | | |
b. To develop a care plan with measurable goals
| | | | | | | |
c. To implement interventions immediately
| | | |
**d. To evaluate patient outcomes | | | |
ANS: B |
Rationale: The planning phase involves developing a care plan with measurable
| | | | | | | | | |
goals and outcomes tailored to the patient’s needs.
| | | | | | | |
NCLEX Preference: Effective planning is key to successful patient outcomes.
| | | | | | | | |
10. How should nursing diagnoses be prioritized?
| | | | |
a. Based on the nurse’s preference
| | | | |