Test Bank For Ackley and Ladwigs Nursing

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

Section I: Nursing Diagnosis, the Nursing Process, and Evidence-

Based Nursing

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

• How should nursing diagnoses be prioritized?

 a. Based on the nurse’s preference