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Nursing Diagnosis Handbook (Exam Questions) 13th Edition

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Nursing Diagnosis Handbook (Exam Questions) 13th Edition

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N T D
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EXAM QUES

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,Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based
Guide to Planning Care 13th Edition (Exam Questions). Mary Beth
Flynn Makic

PLUS
Nursing Outcomes Classification (NOC), 6th edition Outcome Labels and
Definitions (540 Outcomes) and Nursing Interventions Classification
(NIC), 7th edition Intervention Labels & Definitions N=565

Chapter 01: Anxiety
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning
Care 13th Edition, (Exam Questions)
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 medications 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 teaching 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
reportsa 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 anxiety.”
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.
Answer: C
The source of a client’s anxiety 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 department 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?”
Answer: 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 or she looks fine is patronizing and minimizes the client’s concerns, while asking the
client “why” presents a communication block asking the client about problems may not yield a
useful answer as the cause of anxiety is often unknown.
DIF: Cognitive Level: Application/Applying TOP: Nursing Process: Assessment
MSC: Psychosocial Integrity

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