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
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
