Test Bank for Nursing Diagnosis Handbook 12th Edition Ackley ||Complete A+ Guide

Test Bank for Nursing Diagnosis Handbook 12th Edition Ackley |
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,Nursing Diagnosis Handbook 12th Edition Ackley Test Bank
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1.
During the assessment of a client with left-sided weakness who is right-hand
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dominant, the nurse identifies that the client needs assistance with ambulation.
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Which of the following would be the most relevant defining characteristic
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the nursing diagnosis of self-care deficit: bathing in this client?
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a. Inability to access bathroom ssss ssss ssss



b. Inability to dry body ssss s s s s ssss



c. Inability to wash body ssss ssss ssss



d. Inability to regulate bath water ssss ssss ssss s s s s



ANSWER: a
POINTS: 100

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



b. Environmental barriers ssss



c. Inability to perceive body part ssss ssss ssss ssss



d. Inability to perceive spatial relationshipsssss ssss ssss ssss



ANSWER: b
POINTS: 100

3.
The nurse is planning care for a client with severe dementia who becomes agitated
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during bathing. Which of the
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following outcomes would be most applicable for this client‟s nursing diagnosis of self-
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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
POINTS: 100
4.
The nurse is developing the plan of care for a client with dementia. Which of the
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following interventions should the nurse include to preserve the client‟s dignity
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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
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,POINTS: 100




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