Test Bank For Ackley and Ladwig's Nursing
91 91 91 91 91 91 91
Diagnosis Handbook 13th Edition: An Evide
91 91 91 91 91
nce-Based Guide to Planning Care
91 91 91 91
by Mary Beth Flynn Makic
91 91 91 91
@2024
,Section I: Nursing Diagnosis, the Nursing Process, and Evidence-
91 91 91 91 91 91 91 91
Based Nursing
91 91
1. What is the primary goal of a nursing diagnosis?
91 91 91 91 91 91 91 91
a. To identify a medical diagnosis
91 91 91 91 91
b. To determine the effectiveness of medications
91 91 91 91 91 91
c. To identify patient problems that can be managed by nursin
91 91 91 91 91 91 91 91 91 91
g interventions
91
d. To prioritize physician orders
91 91 91 91
ANS: C 91
Rationale: The primary goal of a nursing diagnosis is to identify patient problem
91 91 91 91 91 91 91 91 91 91 91 91
s that can be managed by nursing interventions, focusing on patient care rather th
91 91 91 91 91 91 91 91 91 91 91 91 91
an medical diagnoses.
91 91
NCLEX Preference: Understanding the distinction between nursing and medical
91 91 91 91 91 91 91 91
diagnoses is crucial for patient-centered care.
91 91 91 91 91 91
2. Which component of the nursing diagnosis indicates the problem?
91 91 91 91 91 91 91 91
a. Defining characteristics
91 91
b. Related factors
91 91
c. The actual diagnosis
91 91 91
d. The patient’s history
91 91 91
ANS: C 91
Rationale: The actual diagnosis represents the problem identified in the nursing a
91 91 91 91 91 91 91 91 91 91 91
ssessment. It is essential for formulating a care plan.
91 91 91 91 91 91 91 91
NCLEX Preference: Clear identification of nursing diagnoses is necessary for effe
91 91 91 91 91 91 91 91 91 91
ctive care planning.
91 91
3. What does the "related to" (R/T) statement in a nursing diagnosis signify?
91 91 91 91 91 91 91 91 91 91 91
a. It identifies the patient's response to the problem
91 91 91 91 91 91 91 91
b. It indicates the underlying cause of the problem
91 91 91 91 91 91 91 91
c. It lists the symptoms observed
91 91 91 91 91
d. It describes the treatment plan
91 91 91 91 91
ANS: B 91
Rationale: The "related to" (R/T) statement indicates the underlying cause or con
91 91 91 91 91 91 91 91 91 91 91
tributing factors of the patient’s problem, guiding intervention strategies.
91 91 91 91 91 91 91 91
,NCLEX Preference: Understanding etiology is vital for targeted nursing interve
91 91 91 91 91 91 91 91 91
ntions.
4. Which nursing diagnosis format is used to articulate the problem clearly?
91 91 91 91 91 91 91 91 91 91
a. Problem-focused diagnosis
91 91
b. Risk diagnosis
91 91
c. Health promotion diagnosis
91 91 91
d. All of the above
91 91 91 91
ANS: D 91
Rationale: All formats—problem-focused, risk, and health promotion—
91 91 91 91 91 91
articulate different aspects of patient care and are important in various clinical sit
91 91 91 91 91 91 91 91 91 91 91 91
uations.
NCLEX Preference: Familiarity with different nursing diagnosis formats enhanc
91 91 91 91 91 91 91 91
es clinical reasoning.
91 91
5. In which phase of the nursing process is the nursing diagnosis formulated?
91 91 91 91 91 91 91 91 91 91 91
a. Assessment 91
b. Diagnosis 91
c. Planning
91
d. Implementation
91
ANS: B 91
Rationale: The nursing diagnosis is formulated during the diagnosis phase, after
91 91 91 91 91 91 91 91 91 91 91
collecting and analyzing assessment data.
91 91 91 91
NCLEX Preference: Understanding the nursing process phases is crucial for effe
91 91 91 91 91 91 91 91 91 91
ctive care delivery.
91 91
6. What is a defining characteristic in a nursing diagnosis?
91 91 91 91 91 91 91 91
a. The cause of the problem
91 91 91 91 91
b. The observable signs and symptoms
91 91 91 91 91
c. The expected outcomes
91 91 91
d. The patient's medical history
91 91 91 91
ANS: B 91
Rationale: Defining characteristics are the observable signs and symptoms that v
91 91 91 91 91 91 91 91 91 91
alidate the nursing diagnosis and provide evidence of the problem.
91 91 91 91 91 91 91 91 91
NCLEX Preference: Identifying defining characteristics is essential for accurate di
91 91 91 91 91 91 91 91 91
agnosis and planning. 91 91
, 7. How can a nurse validate a nursing diagnosis?
91 91 91 91 91 91 91
a. By relying solely on personal experience
91 91 91 91 91 91
b. By collecting data from various sources, including the patient
91 91 91 91 91 91 91 91 91
c. By discussing it only with physicians
91 91 91 91 91 91
d. By documenting the diagnosis without evidence
91 91 91 91 91 91
ANS: B 91
Rationale: Validating a nursing diagnosis involves collecting data from multiple
91 91 91 91 91 91 91 91 91 91
sources, including the patient, to ensure accuracy and relevance.
91 91 91 91 91 91 91 91
NCLEX Preference: Validation of nursing diagnoses is critical for patient safety
91 91 91 91 91 91 91 91 91 91 9
and effective care.
1 91 91
8. What role does evidence-based practice play in nursing diagnoses?
91 91 91 91 91 91 91 91
a. It complicates the diagnosis process
91 91 91 91 91
b. It provides a scientific basis for nursing decisions
91 91 91 91 91 91 91 91
c. It is optional for nursing practice
91 91 91 91 91 91
d. It focuses solely on traditional methods
91 91 91 91 91 91
ANS: B 91
Rationale: Evidence- 91
based practice provides a scientific basis for nursing decisions, improving patient
91 91 91 91 91 91 91 91 91 91
outcomes and ensuring care is effective and relevant. NCLEX Preference: Kno
91 91 91 91 91 91 91 91 91 91 91
wledge of evidence-based practice is essential for modern nursing.
91 91 91 91 91 91 91 91
9. What is the purpose of the planning phase in the nursing process?
91 91 91 91 91 91 91 91 91 91 91
a. To assess the patient’s condition
91 91 91 91 91
b. To develop a care plan with measurable goals
91 91 91 91 91 91 91 91
c. To implement interventions immediately
91 91 91 91
**d. To evaluate patient outcomes
91 91 91 91
ANS: B 91
Rationale: The planning phase involves developing a care plan with measurable
91 91 91 91 91 91 91 91 91 91 91
goals and outcomes tailored to the patient’s needs.
91 91 91 91 91 91 91
NCLEX Preference: Effective planning is key to successful patient outcomes.
91 91 91 91 91 91 91 91 91
10. How should nursing diagnoses be prioritized?
91 91 91 91 91
a. Based on the nurse’s preference
91 91 91 91 91
91 91 91 91 91 91 91
Diagnosis Handbook 13th Edition: An Evide
91 91 91 91 91
nce-Based Guide to Planning Care
91 91 91 91
by Mary Beth Flynn Makic
91 91 91 91
@2024
,Section I: Nursing Diagnosis, the Nursing Process, and Evidence-
91 91 91 91 91 91 91 91
Based Nursing
91 91
1. What is the primary goal of a nursing diagnosis?
91 91 91 91 91 91 91 91
a. To identify a medical diagnosis
91 91 91 91 91
b. To determine the effectiveness of medications
91 91 91 91 91 91
c. To identify patient problems that can be managed by nursin
91 91 91 91 91 91 91 91 91 91
g interventions
91
d. To prioritize physician orders
91 91 91 91
ANS: C 91
Rationale: The primary goal of a nursing diagnosis is to identify patient problem
91 91 91 91 91 91 91 91 91 91 91 91
s that can be managed by nursing interventions, focusing on patient care rather th
91 91 91 91 91 91 91 91 91 91 91 91 91
an medical diagnoses.
91 91
NCLEX Preference: Understanding the distinction between nursing and medical
91 91 91 91 91 91 91 91
diagnoses is crucial for patient-centered care.
91 91 91 91 91 91
2. Which component of the nursing diagnosis indicates the problem?
91 91 91 91 91 91 91 91
a. Defining characteristics
91 91
b. Related factors
91 91
c. The actual diagnosis
91 91 91
d. The patient’s history
91 91 91
ANS: C 91
Rationale: The actual diagnosis represents the problem identified in the nursing a
91 91 91 91 91 91 91 91 91 91 91
ssessment. It is essential for formulating a care plan.
91 91 91 91 91 91 91 91
NCLEX Preference: Clear identification of nursing diagnoses is necessary for effe
91 91 91 91 91 91 91 91 91 91
ctive care planning.
91 91
3. What does the "related to" (R/T) statement in a nursing diagnosis signify?
91 91 91 91 91 91 91 91 91 91 91
a. It identifies the patient's response to the problem
91 91 91 91 91 91 91 91
b. It indicates the underlying cause of the problem
91 91 91 91 91 91 91 91
c. It lists the symptoms observed
91 91 91 91 91
d. It describes the treatment plan
91 91 91 91 91
ANS: B 91
Rationale: The "related to" (R/T) statement indicates the underlying cause or con
91 91 91 91 91 91 91 91 91 91 91
tributing factors of the patient’s problem, guiding intervention strategies.
91 91 91 91 91 91 91 91
,NCLEX Preference: Understanding etiology is vital for targeted nursing interve
91 91 91 91 91 91 91 91 91
ntions.
4. Which nursing diagnosis format is used to articulate the problem clearly?
91 91 91 91 91 91 91 91 91 91
a. Problem-focused diagnosis
91 91
b. Risk diagnosis
91 91
c. Health promotion diagnosis
91 91 91
d. All of the above
91 91 91 91
ANS: D 91
Rationale: All formats—problem-focused, risk, and health promotion—
91 91 91 91 91 91
articulate different aspects of patient care and are important in various clinical sit
91 91 91 91 91 91 91 91 91 91 91 91
uations.
NCLEX Preference: Familiarity with different nursing diagnosis formats enhanc
91 91 91 91 91 91 91 91
es clinical reasoning.
91 91
5. In which phase of the nursing process is the nursing diagnosis formulated?
91 91 91 91 91 91 91 91 91 91 91
a. Assessment 91
b. Diagnosis 91
c. Planning
91
d. Implementation
91
ANS: B 91
Rationale: The nursing diagnosis is formulated during the diagnosis phase, after
91 91 91 91 91 91 91 91 91 91 91
collecting and analyzing assessment data.
91 91 91 91
NCLEX Preference: Understanding the nursing process phases is crucial for effe
91 91 91 91 91 91 91 91 91 91
ctive care delivery.
91 91
6. What is a defining characteristic in a nursing diagnosis?
91 91 91 91 91 91 91 91
a. The cause of the problem
91 91 91 91 91
b. The observable signs and symptoms
91 91 91 91 91
c. The expected outcomes
91 91 91
d. The patient's medical history
91 91 91 91
ANS: B 91
Rationale: Defining characteristics are the observable signs and symptoms that v
91 91 91 91 91 91 91 91 91 91
alidate the nursing diagnosis and provide evidence of the problem.
91 91 91 91 91 91 91 91 91
NCLEX Preference: Identifying defining characteristics is essential for accurate di
91 91 91 91 91 91 91 91 91
agnosis and planning. 91 91
, 7. How can a nurse validate a nursing diagnosis?
91 91 91 91 91 91 91
a. By relying solely on personal experience
91 91 91 91 91 91
b. By collecting data from various sources, including the patient
91 91 91 91 91 91 91 91 91
c. By discussing it only with physicians
91 91 91 91 91 91
d. By documenting the diagnosis without evidence
91 91 91 91 91 91
ANS: B 91
Rationale: Validating a nursing diagnosis involves collecting data from multiple
91 91 91 91 91 91 91 91 91 91
sources, including the patient, to ensure accuracy and relevance.
91 91 91 91 91 91 91 91
NCLEX Preference: Validation of nursing diagnoses is critical for patient safety
91 91 91 91 91 91 91 91 91 91 9
and effective care.
1 91 91
8. What role does evidence-based practice play in nursing diagnoses?
91 91 91 91 91 91 91 91
a. It complicates the diagnosis process
91 91 91 91 91
b. It provides a scientific basis for nursing decisions
91 91 91 91 91 91 91 91
c. It is optional for nursing practice
91 91 91 91 91 91
d. It focuses solely on traditional methods
91 91 91 91 91 91
ANS: B 91
Rationale: Evidence- 91
based practice provides a scientific basis for nursing decisions, improving patient
91 91 91 91 91 91 91 91 91 91
outcomes and ensuring care is effective and relevant. NCLEX Preference: Kno
91 91 91 91 91 91 91 91 91 91 91
wledge of evidence-based practice is essential for modern nursing.
91 91 91 91 91 91 91 91
9. What is the purpose of the planning phase in the nursing process?
91 91 91 91 91 91 91 91 91 91 91
a. To assess the patient’s condition
91 91 91 91 91
b. To develop a care plan with measurable goals
91 91 91 91 91 91 91 91
c. To implement interventions immediately
91 91 91 91
**d. To evaluate patient outcomes
91 91 91 91
ANS: B 91
Rationale: The planning phase involves developing a care plan with measurable
91 91 91 91 91 91 91 91 91 91 91
goals and outcomes tailored to the patient’s needs.
91 91 91 91 91 91 91
NCLEX Preference: Effective planning is key to successful patient outcomes.
91 91 91 91 91 91 91 91 91
10. How should nursing diagnoses be prioritized?
91 91 91 91 91
a. Based on the nurse’s preference
91 91 91 91 91
