Test Bank For Ackley and Ladwig-s Nursing Diagnosis Handbook 13th Edition An Evidence-Based Guide to Planning.

1. Which nursing diagnosis would be appropriate for a patient experiencing difficulty breathing due to asthma?  a. Impaired Gas Exchange  b. Ineffective Airway Clearance  c. Anxiety  d. Risk for Infection ANS: A Rationale: "Impaired Gas Exchange" is directly related to the patient’s difficulty breathing due to asthma, affecting oxygenation and carbon dioxide elimination. NCLEX Preference: Prioritizing diagnoses that directly relate to the patient’s immediate physiological needs is crucial for effective care. 2. A patient diagnosed with diabetes presents with elevated blood glucose levels. What is the most appropriate nursing diagnosis?  a. Risk for Unstable Blood Glucose Level  b. Deficient Knowledge regarding diabetes management  c. Ineffective Health Management  d. Impaired Skin Integrity ANS: A Rationale: "Risk for Unstable Blood Glucose Level" is appropriate due to the elevated blood glucose levels, indicating the potential for further complications. NCLEX Preference: Identifying risks associated with a patient’s condition enhances patient safety and management. 3. In planning care for a patient recovering from a stroke, which nursing diagnosis is a priority?  a. Impaired Physical Mobility  b. Acute Pain  c. Impaired Social Interaction  d. Risk for Falls ANS: A Rationale: "Impaired Physical Mobility" is a primary concern in stroke recovery, directly impacting the patient’s rehabilitation and safety. NCLEX Preference: Addressing mobility issues is critical for patient recovery and quality of life. 4. For a patient experiencing chronic pain, which nursing diagnosis would be most appropriate?  a. Acute Pain  b. Ineffective Coping  c. Chronic Pain  d. Risk for Impaired Skin Integrity ANS: C Rationale: "Chronic Pain" accurately reflects the patient’s ongoing experience and requires targeted interventions to manage effectively. NCLEX Preference: Recognizing chronic conditions ensures appropriate and effective nursing care. 5. What nursing diagnosis is appropriate for a patient undergoing chemotherapy who reports nausea and vomiting?  a. Risk for Electrolyte Imbalance  b. Impaired Nutrition: Less than Body Requirements  c. Acute Pain  d. Ineffective Health Management ANS: B Rationale: "Impaired Nutrition: Less than Body Requirements" is relevant due to the effects of chemotherapy on appetite and nutrition. NCLEX Preference: Addressing nutritional needs is essential for recovery and overall health. 6. A patient with hypertension is non-compliant with medication. What nursing diagnosis should be prioritized?  a. Deficient Knowledge regarding hypertension management  b. Ineffective Health Maintenance  c. Noncompliance  **d. Risk for Complications ANS: C Rationale: "Noncompliance" directly addresses the patient’s failure to take prescribed medications, which could lead to adverse health outcomes. NCLEX Preference: Focusing on compliance issues is vital for effective disease management. 7. Which nursing diagnosis would be suitable for a patient showing signs of depression?  a. Hopelessness  b. Risk for Self-Directed Violence  c. Social Isolation  **d. Anxiety ANS: A Rationale: "Hopelessness" is a common nursing diagnosis for patients with depression, highlighting the need for supportive interventions. NCLEX Preference: Identifying mental health issues is critical for holistic care. 8. A patient with renal failure presents with fluid overload. What nursing diagnosis is appropriate?  a. Impaired Skin Integrity  b. Excess Fluid Volume  c. Activity Intolerance  **d. Risk for Infection ANS: B Rationale: "Excess Fluid Volume" reflects the patient’s renal failure condition and guides appropriate interventions such as diuretics. NCLEX Preference: Addressing fluid balance is crucial in renal care management. 9. For a patient recovering from surgery, which nursing diagnosis is a priority?  a. Risk for Infection  b. Acute Pain  c. Impaired Physical Mobility  **d. Anxiety ANS: A Rationale: "Risk for Infection" is critical in the post-operative setting due to potential surgical site complications. NCLEX Preference: Preventing infection is a primary concern in post-surgical care. 10. A patient reports feeling tired and has low energy levels. Which nursing diagnosis should the nurse consider?  a. Activity Intolerance  b. Risk for Fatigue  c. Fatigue  **d. Impaired Physical Mobility ANS: C Rationale: "Fatigue" directly reflects the patient’s experience of tiredness and low energy, guiding the nurse in planning appropriate interventions. NCLEX Preference: Accurate identification of fatigue enhances the quality of nursing care. 11. When assessing a patient with a history of substance abuse, which nursing diagnosis may apply?  a. Risk for Impaired Parenting  b. Ineffective Coping  c. Noncompliance  **d. Chronic Pain ANS: B Rationale: "Ineffective Coping" addresses the challenges the patient may face related to substance abuse, allowing for targeted support. NCLEX Preference: Recognizing coping mechanisms is essential for comprehensive care.