Test Bank: Ackley and Ladwig's Nursing Diagnosis
Handbook, 13th Edition
An Evidence-Based Guide to Planning Care
SECTION I: THE NURSING PROCESS AND CLINICAL REASONING
Chapter 1: The Nursing Process and Clinical Reasoning
Multiple Choice Questions
1. According to Ackley and Ladwig's Nursing Diagnosis Handbook, what is the first phase of
the nursing process?
A) Planning
B) Implementation
C) Assessment
D) Evaluation
Answer: C) Assessment
Rationale: The nursing process follows a five-step scientific method: Assessment, Diagnosis,
Planning, Implementation, and Evaluation (ADPIE). Assessment is the first and most critical
phase, during which the nurse collects comprehensive data about the client's physical,
psychological, social, and spiritual status. Without accurate assessment data, subsequent
phases cannot be effectively completed . This foundational step establishes the baseline for
all clinical reasoning and care planning that follows.
2. The nurse is gathering information about a newly admitted client by reviewing medical
history, interviewing the client, performing a physical examination, and reviewing
laboratory results. This nurse is engaged in which phase of the nursing process?
A) Diagnosis
B) Assessment
C) Planning
D) Evaluation
Answer: B) Assessment
Rationale: The nurse is in the Assessment phase, which involves collecting comprehensive
data from multiple sources, including client interview, physical examination, medical history
review, and laboratory results . Assessment involves gathering both subjective and objective
data to form a complete picture of the client's health status. This comprehensive data
collection is essential before any diagnosis or planning can occur .
3. Which of the following best describes clinical reasoning as defined in Ackley's Nursing
Diagnosis Handbook?
, A) A linear process of following hospital policies and procedures
B) A cognitive process that uses formal and informal thinking to gather and analyze
patient information, evaluate its importance, and determine the value of alternative
actions
C) An intuitive process that relies primarily on nursing experience
D) A step-by-step algorithm for care delivery
Answer: B) A cognitive process that uses formal and informal thinking to gather and
analyze patient information, evaluate its importance, and determine the value of
alternative actions
Rationale: Clinical reasoning is a complex cognitive process that incorporates both formal
and informal thinking to analyze patient information, evaluate its significance, and
determine the value of alternative actions. It is not merely intuitive or algorithmic but
requires critical thinking and evidence-based decision-making . Clinical reasoning is essential
for competent nursing practice and is integrated throughout all phases of the nursing
process .
4. What does the acronym ADPIE represent in the nursing process?
A) Assess, Diagnose, Prescribe, Implement, Evaluate
B) Analyze, Diagnose, Plan, Implement, Evaluate
C) Assess, Diagnose, Plan, Implement, Evaluate
D) Assess, Determine, Plan, Implement, Evaluate
Answer: C) Assess, Diagnose, Plan, Implement, Evaluate
Rationale: ADPIE is the acronym for the five phases of the nursing process: Assessment,
Diagnosis, Planning, Implementation, and Evaluation . This framework provides an
organizing structure for professional nursing practice, allowing nurses to give the best care
to patients using scientific reasoning and problem-solving methods . Each phase builds upon
the previous one, though the process is dynamic and nonlinear .
5. The nurse establishes goals and outcomes and selects interventions during which phase
of the nursing process?
A) Assessment
B) Diagnosis
C) Planning
D) Implementation
Answer: C) Planning
Rationale: The Planning phase involves formulating and writing outcome/goal statements
and determining appropriate nursing interventions based on evidence (research). Goals
must be SMART (Specific, Measurable, Achievable, Realistic, Timely) and focus on what the
patient will achieve . During this phase, the nurse develops the blueprint for care that will
guide implementation .
,6. The nurse implements the care plan and records findings during which phase of the
nursing process?
A) Planning
B) Implementation
C) Evaluation
D) Assessment
Answer: B) Implementation
Rationale: Implementation is the phase where the nurse puts the care plan into action and
records the findings and results . This involves carrying out the planned interventions and
monitoring patient responses. Implementation requires the nurse to use clinical judgment,
technical skills, and therapeutic communication to deliver safe, evidence-based care .
7. Which statement accurately describes the Evaluation phase of the nursing process?
A) It occurs only at the end of the nursing process
B) It involves reviewing outcomes and making necessary revisions in the care plan
C) It is the same as the assessment phase
D) It does not require documentation
Answer: B) It involves reviewing outcomes and making necessary revisions in the care plan
Rationale: The Evaluation phase involves reviewing the outcomes and the nursing care that
has been implemented . The nurse determines whether patient goals were met and makes
necessary revisions in care interventions as needed. If goals are not met, the nurse re-
evaluates and resets goals . Evaluation is a continuous process that occurs throughout the
nursing process, not just at the end.
8. The nursing process is best described as:
A) A linear, step-by-step procedure
B) A nonlinear, dynamic process involving clinical reasoning and judgment
C) A physician-driven protocol
D) A documentation requirement only
Answer: B) A nonlinear, dynamic process involving clinical reasoning and judgment
Rationale: The nursing process is not a linear process but rather a nonlinear, dynamic
process that involves clinical reasoning and judgment, deliberative rationality, and clinical
imagination . The sum total of ADPIE is greater than its individual parts. This dynamic nature
allows nurses to adapt care based on changing patient conditions and new information .
9. According to Ackley's Nursing Diagnosis Handbook, what is the "patient's story"?
A) A written narrative of the patient's medical history
B) The subjective and objective information that describes who the client is as a
person as well as their medical history
C) The patient's personal opinion about healthcare providers
D) A fictional account created to help students practice therapeutic communication
, Answer: B) The subjective and objective information that describes who the client is as a
person as well as their medical history
Rationale: The "patient's story" encompasses both objective and subjective information that
describes who the patient is as a person, their life circumstances, medical history, and
current health concerns . Specific aspects include physiological, psychological, and family
characteristics; available resources; environmental and social context; knowledge; and
motivation . This holistic understanding is essential for developing patient-centered care
plans .
10. What is the primary source for eliciting the patient's story?
A) The electronic health record
B) The patient's family members
C) The patient themselves
D) The primary care provider
Answer: C) The patient themselves
Rationale: While family members and medical records are valuable secondary sources, the
primary source for the patient's story is the patient themselves . Whenever possible, the
nurse should obtain information directly from the patient to ensure accuracy and promote
patient engagement in care. Patient-centered care begins with learning as much as possible
about the client, including their story .
11. Which of the following is NOT one of the three primary goals of nursing as identified in
Ackley's Nursing Diagnosis Handbook?
A) Determine client/family responses to human problems, level of wellness, and
need for assistance
B) Provide physical care, emotional care, teaching, guidance, and counseling
C) Prescribe medications and perform surgical procedures
D) Implement interventions aimed at prevention and assisting the client to meet
their needs and health-related goals
Answer: C) Prescribe medications and perform surgical procedures
Rationale: The three primary goals of nursing are: (1) determining client/family responses to
health problems and their need for assistance; (2) providing holistic care including physical,
emotional, teaching, guidance, and counseling; and (3) implementing preventive
interventions and helping clients meet health-related goals . Prescribing medications and
performing surgery are outside the nursing scope of practice and fall within the physician's
role.
12. During the assessment phase, the nurse collects both subjective and objective data.
Which of the following is an example of subjective data?
A) Blood pressure reading of 140/90 mm Hg
B) Client states, "I feel nauseous and dizzy"
Handbook, 13th Edition
An Evidence-Based Guide to Planning Care
SECTION I: THE NURSING PROCESS AND CLINICAL REASONING
Chapter 1: The Nursing Process and Clinical Reasoning
Multiple Choice Questions
1. According to Ackley and Ladwig's Nursing Diagnosis Handbook, what is the first phase of
the nursing process?
A) Planning
B) Implementation
C) Assessment
D) Evaluation
Answer: C) Assessment
Rationale: The nursing process follows a five-step scientific method: Assessment, Diagnosis,
Planning, Implementation, and Evaluation (ADPIE). Assessment is the first and most critical
phase, during which the nurse collects comprehensive data about the client's physical,
psychological, social, and spiritual status. Without accurate assessment data, subsequent
phases cannot be effectively completed . This foundational step establishes the baseline for
all clinical reasoning and care planning that follows.
2. The nurse is gathering information about a newly admitted client by reviewing medical
history, interviewing the client, performing a physical examination, and reviewing
laboratory results. This nurse is engaged in which phase of the nursing process?
A) Diagnosis
B) Assessment
C) Planning
D) Evaluation
Answer: B) Assessment
Rationale: The nurse is in the Assessment phase, which involves collecting comprehensive
data from multiple sources, including client interview, physical examination, medical history
review, and laboratory results . Assessment involves gathering both subjective and objective
data to form a complete picture of the client's health status. This comprehensive data
collection is essential before any diagnosis or planning can occur .
3. Which of the following best describes clinical reasoning as defined in Ackley's Nursing
Diagnosis Handbook?
, A) A linear process of following hospital policies and procedures
B) A cognitive process that uses formal and informal thinking to gather and analyze
patient information, evaluate its importance, and determine the value of alternative
actions
C) An intuitive process that relies primarily on nursing experience
D) A step-by-step algorithm for care delivery
Answer: B) A cognitive process that uses formal and informal thinking to gather and
analyze patient information, evaluate its importance, and determine the value of
alternative actions
Rationale: Clinical reasoning is a complex cognitive process that incorporates both formal
and informal thinking to analyze patient information, evaluate its significance, and
determine the value of alternative actions. It is not merely intuitive or algorithmic but
requires critical thinking and evidence-based decision-making . Clinical reasoning is essential
for competent nursing practice and is integrated throughout all phases of the nursing
process .
4. What does the acronym ADPIE represent in the nursing process?
A) Assess, Diagnose, Prescribe, Implement, Evaluate
B) Analyze, Diagnose, Plan, Implement, Evaluate
C) Assess, Diagnose, Plan, Implement, Evaluate
D) Assess, Determine, Plan, Implement, Evaluate
Answer: C) Assess, Diagnose, Plan, Implement, Evaluate
Rationale: ADPIE is the acronym for the five phases of the nursing process: Assessment,
Diagnosis, Planning, Implementation, and Evaluation . This framework provides an
organizing structure for professional nursing practice, allowing nurses to give the best care
to patients using scientific reasoning and problem-solving methods . Each phase builds upon
the previous one, though the process is dynamic and nonlinear .
5. The nurse establishes goals and outcomes and selects interventions during which phase
of the nursing process?
A) Assessment
B) Diagnosis
C) Planning
D) Implementation
Answer: C) Planning
Rationale: The Planning phase involves formulating and writing outcome/goal statements
and determining appropriate nursing interventions based on evidence (research). Goals
must be SMART (Specific, Measurable, Achievable, Realistic, Timely) and focus on what the
patient will achieve . During this phase, the nurse develops the blueprint for care that will
guide implementation .
,6. The nurse implements the care plan and records findings during which phase of the
nursing process?
A) Planning
B) Implementation
C) Evaluation
D) Assessment
Answer: B) Implementation
Rationale: Implementation is the phase where the nurse puts the care plan into action and
records the findings and results . This involves carrying out the planned interventions and
monitoring patient responses. Implementation requires the nurse to use clinical judgment,
technical skills, and therapeutic communication to deliver safe, evidence-based care .
7. Which statement accurately describes the Evaluation phase of the nursing process?
A) It occurs only at the end of the nursing process
B) It involves reviewing outcomes and making necessary revisions in the care plan
C) It is the same as the assessment phase
D) It does not require documentation
Answer: B) It involves reviewing outcomes and making necessary revisions in the care plan
Rationale: The Evaluation phase involves reviewing the outcomes and the nursing care that
has been implemented . The nurse determines whether patient goals were met and makes
necessary revisions in care interventions as needed. If goals are not met, the nurse re-
evaluates and resets goals . Evaluation is a continuous process that occurs throughout the
nursing process, not just at the end.
8. The nursing process is best described as:
A) A linear, step-by-step procedure
B) A nonlinear, dynamic process involving clinical reasoning and judgment
C) A physician-driven protocol
D) A documentation requirement only
Answer: B) A nonlinear, dynamic process involving clinical reasoning and judgment
Rationale: The nursing process is not a linear process but rather a nonlinear, dynamic
process that involves clinical reasoning and judgment, deliberative rationality, and clinical
imagination . The sum total of ADPIE is greater than its individual parts. This dynamic nature
allows nurses to adapt care based on changing patient conditions and new information .
9. According to Ackley's Nursing Diagnosis Handbook, what is the "patient's story"?
A) A written narrative of the patient's medical history
B) The subjective and objective information that describes who the client is as a
person as well as their medical history
C) The patient's personal opinion about healthcare providers
D) A fictional account created to help students practice therapeutic communication
, Answer: B) The subjective and objective information that describes who the client is as a
person as well as their medical history
Rationale: The "patient's story" encompasses both objective and subjective information that
describes who the patient is as a person, their life circumstances, medical history, and
current health concerns . Specific aspects include physiological, psychological, and family
characteristics; available resources; environmental and social context; knowledge; and
motivation . This holistic understanding is essential for developing patient-centered care
plans .
10. What is the primary source for eliciting the patient's story?
A) The electronic health record
B) The patient's family members
C) The patient themselves
D) The primary care provider
Answer: C) The patient themselves
Rationale: While family members and medical records are valuable secondary sources, the
primary source for the patient's story is the patient themselves . Whenever possible, the
nurse should obtain information directly from the patient to ensure accuracy and promote
patient engagement in care. Patient-centered care begins with learning as much as possible
about the client, including their story .
11. Which of the following is NOT one of the three primary goals of nursing as identified in
Ackley's Nursing Diagnosis Handbook?
A) Determine client/family responses to human problems, level of wellness, and
need for assistance
B) Provide physical care, emotional care, teaching, guidance, and counseling
C) Prescribe medications and perform surgical procedures
D) Implement interventions aimed at prevention and assisting the client to meet
their needs and health-related goals
Answer: C) Prescribe medications and perform surgical procedures
Rationale: The three primary goals of nursing are: (1) determining client/family responses to
health problems and their need for assistance; (2) providing holistic care including physical,
emotional, teaching, guidance, and counseling; and (3) implementing preventive
interventions and helping clients meet health-related goals . Prescribing medications and
performing surgery are outside the nursing scope of practice and fall within the physician's
role.
12. During the assessment phase, the nurse collects both subjective and objective data.
Which of the following is an example of subjective data?
A) Blood pressure reading of 140/90 mm Hg
B) Client states, "I feel nauseous and dizzy"
