Test Bank For Ackley And Ladwig's Nursing Diagnosis Handbook 13th
Edition: An Evidence-Based Guide To Planning Care
By Mary Beth Flynn Makic 2024
All Sections (1-3) | Q&As Verified With Rationales| Grade A+ Assured
ISBN 9780323776837
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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
CORRECT ANSWER 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
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• 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
• c. The expected outcomes
• d. The patient's medical history
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
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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
• b. To develop a care plan with measurable goals
• c. To implement interventions immediately
• **d. To evaluate patient outcomes
CORRECT ANSWER 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
• b. According to the order of documentation
• c. By assessing the urgency and potential for harm
• d. Randomly, as they are all equally important
CORRECT ANSWER C
Rationale: Nursing diagnoses should be prioritized based on urgency and potential for harm,
ensuring that critical patient issues are addressed first.
NCLEX Preference: Prioritization is fundamental for safe nursing practice.
11. Which term describes a nursing diagnosis that indicates a potential problem?
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