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Questions and Answers
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,Nursing Diagnosis Handbook 12th Edition Ackley Test Bank
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1.
During x the x assessment x of x a x client x with x left-sided x weakness x who x is x right-hand x dominant, x the x nurse
xidentifies xthat x the x client x needs x assistance x with x ambulation. x Which x of x the x following x would x be x the
x most x relevant xdefining x characteristic x for x the x nursing x diagnosis x of x self-care x deficit: x bathing x in x this
x client?
a. Inability x to x access x bathroom
b. Inability x to x dry x body
c. Inability x to x wash x body
d. Inability x to x regulate x bath x water
ANSWER: a
POINTS: 100
2.
The x nurse x is x developing x a x plan x of x care x for x a x client x who x has x left-sided x weakness. x Since x there x is x only
x a x tub xfor x bathing x in x the x home, x the x nurse x recognizes x that x there x is x a x self-care x deficit: x bathing x related
x to x which x of xthe xfollowing?
a. Severe x anxiety
b. Environmental x barriers
c. Inability x to x perceive x body x part
d. Inability x to x perceive x spatial x relationships
ANSWER: b
POINTS: 100
3.
The x nurse x is x planning x care x for x a x client x with x severe x dementia x who x becomes x agitated x during x bathing.
x Which xof xthe
following x outcomes x would x be x most x applicable x for x this x client’s x nursing x diagnosis x of x self-care x deficit:
x bathing?
a. x Client x will x state x satisfaction x with x ability x to x use x adaptive x devices x to x bathe.
b. xClient x will x bathe x self x safely x with x minimal x difficulty.
c. xClient x will x bathe x with x assistance x of x caregiver x as x needed x and x report x satisfaction.
d. xClient x will x bathe x with x assistance x without x exhibiting x defensive x behaviors.
ANSWER: d
POINTS: 100
4.
The x nurse x is x developing x the x plan x of x care x for x a x client x with x dementia. x Which x of x the x following
x interventions xshould x the x nurse x include x to x preserve x the x client’s x dignity x during x bathing?
a. x Provide x privacy x and x encourage x client x participation.
b. x Give x analgesics x 30 x minutes x prior x to x bathing.
c. x Provide x client x with x a x padded x shower x chair.
d. x Use x a x prepackaged x bath.
ANSWER: a
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,POINTS: 100
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