CDM Final
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 - ANS -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 - ANS -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. - ANS -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. - ANS -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. - ANS -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 - ANS -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 - ANS -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. - ANS -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 - ANS -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. - ANS -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
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 - ANS -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 - ANS -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. - ANS -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. - ANS -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. - ANS -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 - ANS -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 - ANS -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. - ANS -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 - ANS -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. - ANS -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
