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