TEST BANK for Ackley and Ladwig's
Nursing Diagnosis Handbook 13th Edition:
An Evidence-Based Guide to Planning Care
Edition by Mary Beth Flynn Makic &
Marina Reyna Martinez-Kratz
Complete Chapters With Rationales| A+ PASS
GUARANTEED
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, 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
CORRECT ANSWER: 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
CORRECT ANSWER: 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
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CORRECT ANSWER: B
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Do
c
,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
CORRECT ANSWER: 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
CORRECT ANSWER: 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
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c. The expected outcomes
d. The patient's medical history
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, CORRECT ANSWER: 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
CORRECT ANSWER: 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
CORRECT ANSWER: 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
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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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Do
c
Nursing Diagnosis Handbook 13th Edition:
An Evidence-Based Guide to Planning Care
Edition by Mary Beth Flynn Makic &
Marina Reyna Martinez-Kratz
Complete Chapters With Rationales| A+ PASS
GUARANTEED
Ar
ch
1
Do
c
, 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
CORRECT ANSWER: 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
CORRECT ANSWER: 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
Ar
CORRECT ANSWER: B
ch
2
Do
c
,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
CORRECT ANSWER: 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
CORRECT ANSWER: 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
Ar
c. The expected outcomes
d. The patient's medical history
ch
3
Do
c
, CORRECT ANSWER: 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
CORRECT ANSWER: 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
CORRECT ANSWER: 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
Ar
b. To develop a care plan with measurable goals
ch
c. To implement interventions immediately
4
Do
c
