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