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Test Bank For Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care 13th Edition (2024). Mary Beth Flynn Makic - All Chapters 1-30 PLUS Nursing Outcomes Classification (NOC), 6th edition Outcome Labels and Definitions $44.99
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Test Bank For Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care 13th Edition (2024). Mary Beth Flynn Makic - All Chapters 1-30 PLUS Nursing Outcomes Classification (NOC), 6th edition Outcome Labels and Definitions
Test Bank For Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care 13th Edition (2024). Mary Beth Flynn Makic - All Chapters 1-30
PLUS Nursing Outcomes Classification (NOC), 6th edition Outcome Labels and Definitions (540 Outcomes) and Nursing Interventions Cl...
TEST BANK Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence -Based Guid e to Planning Care 13th Edition , Makic TEST BANK Chapter 01: Anxiety Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence -Based Guide to Planning Care 13th Edition , (2024) Test Bank Multiple Choice 1. A client presents to the urgent care clinic complaining of a feeling of unease and anxiety without a known cause. While conducting the assessment, what other finding should the nurse be most alert for? a. Excessive salivation b. Diabetes c. Diarrhea d. Heart failure Answer: C Diarrhea is a common manifestation of anxiety resulting from activation of the sympathetic nervous system. The other assessment findings are not related to anxiety. DIF: Cognitive Level: Knowledge/Remembering TOP: Nursing Process: Assessment MSC: Psychosocial Integrity 2. A nurse has provided discharge teaching to a client with moderate anxiety. Which statement by the client indicates the teaching has been effective? a. “It’s OK to have 1 -2 drinks a day to help relieve my anxiety.” b. “I can double my m edications if I feel really anxious sometimes.” c. “If I practice my breathing exercises, I will never be anxious again.” d. “I will keep the phone number for the anxiety hotline with me.” Answer: D The use of appropriate community resources is an important tea ching topic for the client with anxiety. Breathing exercises may help but will not “cure” the client. Doubling medications on one’s own can be dangerous and is not advised. Drinking, or using other substances to relieve anxiety, is not recommended and can lead to substance misuse. DIF: Cognitive Level: Comprehension/Understanding TOP: Nursing Process: Evaluation MSC: Psychosocial Integrity 3. The nurse’s aide is taking vital signs on a client admitted with severe anxiety. The aide reports a blood pressure of 90/58 mm Hg, a pulse of 56 beats per minute, and respirations of 10 breaths per minute. Which statement by the nurse is most accurate? a. “Vital signs do not give accurate information about anxiety.” b. “Lowered blood pressure and pulse can be a sign of anx iety.” c. “If he were anxious, his blood pressure would be sky -high.” d. “The client must be less anxious than previously.” Answer: B Defining characteristics for this diagnosis include changes in vital signs from either sympathetic or parasympathetic input. A lowered blood pressure and pulse result from parasympathetic input. DIF: Cognitive Level: Knowledge/Remembering TOP: Integrated Process: Communication and Documentation MSC: Psychosocial Integrity 4. Which of the following does the nurse understand about anxiety? a. The client always knows the source of the anxiety. b. There are no physical manifestations of anxiety. c. Often the source of the anxiety is not known to the client. d. The client never knows the source of the anxiety. Answe r: C The source of a client’s an xiety may not be known to the client and results in a vague , uneasy sense of dread that is hard to pinpoint. DIF: Cognitive Level: Knowledge/Remembering TOP: Nursing Process: Assessment MSC: Psychosocial Integrity 5. A client presents to the emergency dep artment with symptoms of severe anxiety. Which question or statement by the nurse would be most important? “Have you been using alcohol or other drugs recently?” “You look fine to me. Why are you so anxious?” “Does anyone else in your family have anxiety?” “What problems are you having in your life right now?” Answe r: A Withdrawal from cigarettes, alcohol, or other drugs can precipitate anxiety. A family history may be contributory but should not be prioritized before the possibility of withdrawal. Telling a client that he o r she looks fine is patronizing and minimizes the client’s concerns, while asking the client “why” presents a commun ication block asking the client about problems may not yield a useful answer as the cause of anxiety is often unknown. DIF: Cognitiv e Level: Application/Applying TOP: Nursing Process: Assessment MSC: Psychosocial Integrity Chapter 02 : Bathing Self Care De ficit Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence -Based Guide to Planning Care 13th Edition , (2024) Test Bank Multiple Choice Question 1 of 5 During the assessment of a client with left -sided weakness who is right -hand dominant, the nurse identifies that the client needs assistance with ambulation. Which of the following would be the most relevant defining characteristic for the nursing diagnosis of bathing self -care deficit in this client? a) Inability to regulate bath water b) Inability to access bathroom c) Inability to dry body d) Inability to wash body Correct c) Inabil ity to access bathroom This client has a mobility limitation and requires assistance to ambulate, which limits h is or her ability to access the bathroom without assistance. Since the client’s weak side is not the dominant side, washing and drying should no t be a problem. There is no information about cognitive or fine motor skill deficits that would l ead to an inability to regulate water temperature. DIF: Cognitive Level: Analysis/Analyzing TOP: Nursing Process: Diagnosis MSC: Physiological Integrity: Basic Care and Comfort Quest ion 2 of 5 The nurse is developing a plan of care for a client who has left -sided weakness. Since there i s only a tub for bathing in the home, the nurse recognizes that there is a bathing self -care deficit related to which of the following? a) Environmental ba rriers b) Severe anxiety c) Inability to perceive body part d) Inability to perceive spatial relationships
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