CDM Final Exam Questions With Verified Answers

The nurse is planning care for a client who has severe arthritis and has very limited fine motor hand dexterity. Which of the following would the nurse identify as the most relevant defining characteristic for this client for the nursing diagnosis of Self-Care Deficit: Dressing? Inability to choose clothing Inability to maintain appearance Inability to use zippers Impaired ability to obtain clothing - Answer Inability to use zippers- With limited fine motor dexterity in the hands, the client would most likely have trouble with using zippers, an action that requires fine motor skills. There is no information that suggests the client is unable to choose clothing, maintain appearance, or obtain clothing. The nurse is developing a plan of care for a client who has advanced dementia. The nurse recognizes that there is a Self-Care Deficit: Dressing related to which of the following? Anxiety Cognitive impairment Environmental barriers Weakness - Answer Cognitive impairment- A client with advanced dementia has significant cognitive impairment that could hinder dressing. There is no information about the client having anxiety, weakness, or environmental barriers that make dressing difficult. The nurse is planning care during rehabilitation for a client who experienced left sided weakness following a stroke. Which of the following outcomes would be the most desirable for this client's nursing diagnosis of Self-Care Deficit: Dressing? Client will dress and groom self to optimal potential. Client will identify types of assistive technology. Client will be dressed by a caregiver. Client will explore potential barriers to dressing. - Answer Client will dress and groom self to optimal potential- Dressing and grooming oneself shows the most independence of all the options and therefor is the most desirable outcome. Identifying asistive technology and exploring barriers to dressing assists in developing independence. Being dressed by a caregiver is the least optimal choice as it shows maximal dependence on others. A client had a recent fall and has residual dizziness. What action by the nurse best promotes safety for the client during dressing? Have the client sit for as much dressing as possible. Perform the majority of dressing for the client. Teach the client to hold the bed with one hand. Use a gait belt in case the patient falls during dressing. - Answer Have the client sit for as much dressing as possible- For safety, a patient with dizziness and a history of falls should sit for as much of dressing as possible as this activity can be tiring. Using a gait belt does help prevent falls, but sitting is a better option. Holding the bed with one hand limits the amount of self-dressing the client can do. The nurse performing most of the dressing does not help the client gain or maintain independence. The nurse is teaching a client who has right sided weakness due to a stroke methods for easier dressing. Which of the following interventions should the nurse include in this teaching session? Stand while dressing. Use clothing that fastens in the back. Use smart machine-based prompting. Dress the affected side first. - Answer Dress the affected side first- Dressing the affected side allows for easier manipulation of the client's clothing. A client with weakness may prefer to sit during dressing. Machine-based prompting is helpful for clients with cognitive problems. Clothes that fasten in the back are more difficult to manipulate. The nurse is developing a plan of care for a right hand dominant client who had a right rotator cuff repair. The nurse recognizes that there is a Self-Care Deficit: Feeding related to which of the following? Environmental barriers Musculoskeletal impairment Neuromuscular impairment Perceptual impairment - Answer Musculoskeletal impairment- The musculoskeletal impairment secondary to a surgical procedure on the dominant side is the most appropriate defining characteristic for this client's diagnosis. There is no indication that the client is experiencing environmental barriers, neuromuscular impairment, or perceptual impairment. The nurse is planning care for a client who has Parkinson's disease with severe hand tremors. Which of the following would the nurse identify as the most relevant defining characteristic for this client for the nursing diagnosis of Self-Care Deficit: Feeding? Inability to cook food Inability to chew food Inability to bring food to mouth Impaired ability to manipulate food in mouth - Answer Inability to bring food to mouth- While all options are possible defining characteristics for this diagnosis, the severe hand tremors would limit this client's ability to bring food from a plate or bowl to the mouth. The nurse is planning care for a client who is left hand dominant and is experiencing right sided weakness and a frequent cough following a stroke. Which of the following outcomes would be the most desirable for this client's nursing diagnosis of Self-Care Deficit: Feeding? Client will feed self safely. Client will identify assistive technology for feeding. Client will use adaptive utensils for feeding. Client will explore potential barriers to feeding. - Answer Client will feed self safely- The client's frequent cough after a stroke can indicate aspiration. Patient safety is a high priority. The most optimal goal for the client is to be able to self-feed safely, without aspiration or choking. The client may or may not need to identify assistive technology and use adaptive utensils. Exploring barriers to feeding is also useful, but is not as optimal an outcome as being able to self-feed safely. The nurse is providing a training session for the staff who participates in assisting clients with eating. Which of the following timeframes should the nurse convey is needed per client meal to promote weight gain in at risk clients? 10 minutes 13 minutes 20 minutes 42 minutes - Answer 42 Minutes- A recent research study showed that allowing clients at risk for weight loss an average of 42 minutes to eat meals was associated with better oral intake and weight gain. The other timeframes are too short. The nurse is planning care for a client receiving a tube feeding. Which one of the following interventions for the client should the nurse include for safety to help prevent aspiration pneumonia? Swab mouth once each shift with foam toothettes. Provide regular oral care using toothbrush. Avoid oral care to reduce oral secretions Apply moisturizer to lips every 4 hours. - Answer Provide regular oral care using toothbrush- Clients on tube feedings have been found to have poorer oral care than those not on tube feedings, leading to an increased incidence of aspiration pneumonia. Using foam toothettes once a shift does not provide adequate hygiene. Applying moisturizer and avoiding oral care will not help prevent aspiration pneumonia. During assessment the nurse identifies that a client needs assistance with ambulation. Which of the following would the nurse identify as the most relevant defining characteristic for this client's nursing diagnosis Self-Care Deficit: Toileting? Inability to manipulate clothing for toileting Inability to get to toilet or commode Inability to wash hands after toileting Inability to carry out proper toilet hygiene - Answer Inability to get to toilet or commode- Ambulation difficulties would most likely lead to a client not being able to get to the bathroom or to the commode easily. There is no information to suggest the client cannot manipulate clothing, wash hands, or carry out hygiene activities. The nurse is developing a plan of care for a client who uses a wheelchair and requires toileting assistance. The nurse recognizes that there is a Self-Care Deficit: Toileting related to which of the following? Impaired transfer ability Environmental factors Fatigue Decreased motivation - Answer Impaired transfer ability- A client using a wheelchair most likely has a Self Care Deficit in toileting related to his/her ability to transfer safety from the wheelchair to commode or toilet. Environmental factors may be implicated if the wheelchair does not fit in the bathroom; in this case the nurse should obtain a commode. There is no indication that the client suffers from fatigue or decreased motivation. The nurse is planning care for a client who experienced a traumatic amputation of the right arm. Which of the following outcomes would be most applicable for this client's nursing diagnosis of Self-Care Deficit: Toileting? Client will toilet safely. Client will state satisfaction with ability to use adaptive devices for toileting. Client will toilet with assistance of caregiver. Client will wear adult incontinence briefs for safety. - Answer Client will state satisfaction with ability to use adaptive devices for toileting- Adaptive devices for toileting can promote independence. While the ability to toilet safely is a good long term goal, this client most likely needs adaptive devices in order to do so. Satisfaction with adaptive devices will lead to compliance and consistency in their use. The client should be encouraged to be as independent as possible, so toileting with a caregiver's assistance is not the most optimal outcome. There should be no need for this client to wear incontinence briefs. The nurse is planning to place a client with a fractured hip on a bed pan. Which one of the following interventions has research shown would be most effective in reducing the client's anxiety about its use? Placing waterproof pads on bed. Provide analgesics 30 minutes after bed pan use. Warm bedpan with hot water. Discuss use of bed pan with client prior to its use. - Answer Discuss use of bed pan with client prior to its use.- Studies show that some clients may have less anxiety about using a bedpan when the nurse discusses its use beforehand. Waterproof pads, analgesics, and warming the bedpan will not help decrease anxiety. A nurse is caring for a hospitalized client with urinary frequency. What action by the nurse best promotes patient safety? Assess the client's fall risk with a standardized tool. Obtain a prescription for an indwelling catheter. Provide a bedside commode for the client to use. Remind the client to get assistance with toileting. - Answer Assess the client's fall risk with a standardized tool.- A recent study showed that over 45% of falls were related to toileting. One predictor for falling was being identified as a fall risk. Nurses should assess their clients' fall risk using a standardized tool before planning specific interventions based on the outcome. Reminding the client not to get up is important, but with urgency, the client may not be able to wait. A bedside commode might be helpful with the frequency but will not prevent falls when getting up to use it. Indwelling catheters are associated with increased risk of bladder infections. A nurse is caring for a client with the diagnosis of Readiness for Enhanced Comfort. Which of the following Nursing Outcomes Classification (NOC) outcomes would be inconsistent with the nurse's knowledge of this diagnosis? Symptom control Comfort status Spiritual Health Secondary health promotion - Answer Secondary Health Promotion- Symptom control, comfort status, and spiritual health are all NOC outcomes for this diagnosis. Secondary health promotion is not. The mother of an infant is distressed because the baby needs to have blood drawn. What instruction by the nurse would decrease both the mother's and the baby's discomfort? Encourage the mother to hold the baby in a skin-to-skin embrace. Assure the mother that the baby cannot feel any real pain. Take the baby from the mother during the blood draw procedure. Swaddle the baby snugly except for the area of the venipuncture - Answer Encourage the mother to hold the baby in a skin-to-skin embrace.- Skin-to-skin contact is a very comforting intervention. Research specifically demonstrates that newborns showed a decreased response to pain during venipuncture while being held skin-to-skin. If the baby has less discomfort, the mother will also be less distressed. Babies can feel pain. Taking the baby away will increase anxiety in both baby and mother and anxiety can increase perceived pain. Swaddling the baby may provide comfort but has not been shown to be correlated with less pain during venipuncture The nurse is caring for a client with dementia who appears to be in discomfort. Which intervention should the nurse attempt with this client? Guided imagery Healing touch Simple massage Distraction techniques - Answer Simple Massage- A recent study showed that elders with dementia and agitation responded positively to simple massage. A person with dementia most likely could not participate in guided imagery or use distraction techniques. Healing touch can be helpful for clients who cannot tolerate more simulating interventions, but requires training and would not be tried before the more simple massage techniques. The nurse is caring for a post-operative client from an unfamiliar culture. The nurse is frustrated because the client will not take pain medication, but refuses to get out of bed. What action by the nurse is best? Teach the client how pain control helps with increasing activity. Give the client pain medications without explaining what they are. Ask the client what pain and illness represent in his/her culture. Have the provider discuss pain medication with the client. - Answer Ask the client what pain and illness represent in his/her culture.- The nurse realizes that culture influences health beliefs, communication, values, and health-care practices. The nurse should assess how this client's culture is affecting the decisions the client is making. Then the nurse and client can plan a pain management strategy together. Teaching the client is always good, but without being able to provide culturally competent care, the client is not likely to change behaviors. "Sneaking" medications to an uninformed client is unethical. Having the provider give the client information is also unlikely to elicit any changes.