Nursing Diagnosis Handbook 12th Edition Ackley Test Bank | Verified Answers

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




b. Inability to dry body kj k j kj




c. Inability to wash body kj kj k j




d. Inability to regulate bath water kj kj kj k j




ANSWER: a
POINTS: 100

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




b. Environmental barriers kj




c. Inability to perceive body part kj k j kj k j




d. Inability to perceive spatial relationships kj kj kj k j




ANSWER: b
POINTS: 100

3.
The nurse is planning care for a client with severe dementia who becomes agitated during bathing.
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Which of the
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following outcomes would be most applicable for this client‟s nursing diagnosis of self-care deficit:
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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 following
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interventions should 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

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,POINTS: 100




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