Ackley and Ladwig’s Nursing Diagnosis Handbook Test Bank 13th Edition | Makic, Martinez-Kratz

TEST BANK
Ackley and Ladwig’s Nursing Diagnosis Handbook: An
Evidence-Based Guide to Planning Care
MARY BETH FLYNN MAKIC, MARINA REYNA MARTINEZ-KRATZ
13th Edition

,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