Nursing Diagnosis Handbook 12th Edition Ackley Test Bank

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, Nursing Diagnosis Handbook 12th Edition Ackley Test Bankv v v v v v v



1.
During the assessment of a client with left-sided weakness who is right-hand dominant, the nurse identifies that
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the client needs assistance with ambulation. Which of the following would be the most relevant defining
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characteristic for the nursing diagnosis of self-care deficit: bathing in this client?
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a. Inability to access bathroom v v v



b. Inability to dry body v v v



c. Inability to wash body v v v



d. Inability to regulate bath water v v v v



ANSWER: a v



POINTS: 100

2.
The nurse is developing a plan of care for a client who has left-sided weakness. Since there is only a tub for
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bathing in the home, the nurse recognizes that there is a self-care deficit: bathing related to which of the
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following?
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a. Severe anxiety v



b. Environmental barriers v



c. Inability to perceive body part v v v v



d. Inability to perceive spatial relationships v v v v



ANSWER: b v



POINTS: 100

3. GRADESLAB.COM
The nurse is planning care for a client with severe dementia who becomes agitated during bathing. Which of the
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following outcomes would be most applicable for this client‟s nursing diagnosis of self-care deficit: bathing?
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a. Client will state satisfaction with ability to use adaptive devices to bathe.
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b. Client will bathe self safely with minimal difficulty.
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c. Client will bathe with assistance of caregiver as needed and report satisfaction.
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d. Client will bathe with assistance without exhibiting defensive behaviors.
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ANSWER: d v



POINTS: 100
4.
The nurse is developing the plan of care for a client with dementia. Which of the following interventions should
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the nurse include to preserve the client‟s dignity during bathing?
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a. Provide privacy and encourage client participation.
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b. Give analgesics 30 minutes prior to bathing.
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c. Provide client with a padded shower chair.
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d. Use a prepackaged bath.
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ANSWER: a v



POINTS: 100

5.
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,In planning care for a client with dementia, the nurse should train caregivers bathing the client to use which of
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, the following behaviors to reduce aggression in the client?
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a. Avoid prior cueing for client.
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b. Increase the speed of the bath.
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c. Prepare client before water spray.
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d. Wash client‟s hair and face first.
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ANSWER: c v



POINTS: 100

6.
The nurse is planning care for a client who has severe arthritis and has very limited fine motor hand dexterity.
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Which of the following would the nurse identify as the most relevant defining characteristic for this client for
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the nursing diagnosis of self-care deficit: dressing?
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a. Inability to choose clothing
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b. Inability to maintain appearance
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c. Inability to use zippers
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d. Impaired ability to obtain clothing
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ANSWER: c v



POINTS: 100

7.
The nurse is developing a plan of care for a client who has advanced dementia. The nurse recognizes that there
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is a self-care deficit: dressing related to which of the following?
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a. Anxiety v GRADESLAB.COM
b. Cognitive impairment
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c. Environmental barriers
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d. Weakness v



ANSWER: b
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POINTS: 100
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8.
The nurse is planning care during rehabilitation for a client who experienced left-sided weakness following a
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stroke. Which of the following outcomes would be the most desirable for this client‟s nursing diagnosis of self-
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care deficit: dressing?
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a. Client will dress and groom self to optimal potential.
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b. Client will identify types of assistive technology.
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c. Client will be dressed by a caregiver.
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d. Client will explore potential barriers to dressing.
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ANSWER: a v



POINTS: 100

9.
A client had a recent fall and has residual dizziness. What action by the nurse best promotes safety for the client
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during dressing?
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a. Have the client sit for as much dressing as possible.
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