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