Page b1
, Nursing Diagnosis Handbook 12th Edition Ackley Test Bankb b b b b b b
1.
During the assessment of a client with left-sided weakness who is right-hand dominant, the nurse identifies that
b b b b b b b b b b b b b b b b
the client needs assistance with ambulation. Which of the following would be the most relevant defining
b b b b b b b b b b b b b b b b
characteristic for the nursing diagnosis of self-care deficit: bathing in this client?
b b b b b b b b b b b b
a. Inability to access bathroom b b b
b. Inability to dry body b b b
c. Inability to wash body b b b
d. Inability to regulate bath water b b b b
ANSWER: a b
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
b b b b b b b b b b b b b b b b b b b b b
bathing in the home, the nurse recognizes that there is a self-care deficit: bathing related to which of the
b b b b b b b b b b b b b b b b b b b
following?
b
a. Severe anxiety b
b. Environmental barriers b
c. Inability to perceive body part b b b b
d. Inability to perceive spatial relationships b b b b
ANSWER: b b
POINTS: 100
3. GRADESLAB.COM
The nurse is planning care for a client with severe dementia who becomes agitated during bathing. Which of the
b b b b b b b b b b b b b b b b b b
following outcomes would be most applicable for this client‟s nursing diagnosis of self-care deficit: bathing?
b b b b b b b b b b b b b b
a. Client will state satisfaction with ability to use adaptive devices to bathe.
b b b b b b b b b b b
b. Client will bathe self safely with minimal difficulty.
b b b b b b b
c. Client will bathe with assistance of caregiver as needed and report satisfaction.
b b b b b b b b b b b
d. Client will bathe with assistance without exhibiting defensive behaviors.
b b b b b b b b
ANSWER: d b
POINTS: 100
4.
The nurse is developing the plan of care for a client with dementia. Which of the following interventions should
b b b b b b b b b b b b b b b b b b
the nurse include to preserve the client‟s dignity during bathing?
b b b b b b b b b b
a. Provide privacy and encourage client participation.
b b b b b b
b. Give analgesics 30 minutes prior to bathing.
b b b b b b b
c. Provide client with a padded shower chair.
b b b b b b b
d. Use a prepackaged bath.
b b b b
ANSWER: a b
POINTS: 100
5.
Page b2
,In planning care for a client with dementia, the nurse should train caregivers bathing the client to use which of
b b b b b b b b b b b b b b b b b b b
Page b3
, the following behaviors to reduce aggression in the client?
b b b b b b b b
a. Avoid prior cueing for client.
b b b b b
b. Increase the speed of the bath.
b b b b b b
c. Prepare client before water spray.
b b b b b
d. Wash client‟s hair and face first.
b b b b b b
ANSWER: c b
POINTS: 100
6.
The nurse is planning care for a client who has severe arthritis and has very limited fine motor hand dexterity.
b b b b b b b b b b b b b b b b b b b
Which of the following would the nurse identify as the most relevant defining characteristic for this client for
b b b b b b b b b b b b b b b b b b
the nursing diagnosis of self-care deficit: dressing?
b b b b b b b
a. Inability to choose clothing
b b b b
b. Inability to maintain appearance
b b b b
c. Inability to use zippers
b b b b
d. Impaired ability to obtain clothing
b b b b b
ANSWER: c b
POINTS: 100
7.
The nurse is developing a plan of care for a client who has advanced dementia. The nurse recognizes that there
b b b b b b b b b b b b b b b b b b b
is a self-care deficit: dressing related to which of the following?
b b b b b b b b b b b
a. Anxiety b GRADESLAB.COM
b. Cognitive impairment
b b
c. Environmental barriers
b b
d. Weakness b
ANSWER: b
b b
POINTS: 100
b
8.
The nurse is planning care during rehabilitation for a client who experienced left-sided weakness following a
b b b b b b b b b b b b b b b
stroke. Which of the following outcomes would be the most desirable for this client‟s nursing diagnosis of self-
b b b b b b b b b b b b b b b b b b
care deficit: dressing?
b b b
a. Client will dress and groom self to optimal potential.
b b b b b b b b b
b. Client will identify types of assistive technology.
b b b b b b b
c. Client will be dressed by a caregiver.
b b b b b b b
d. Client will explore potential barriers to dressing.
b b b b b b b
ANSWER: a b
POINTS: 100
9.
A client had a recent fall and has residual dizziness. What action by the nurse best promotes safety for the client
b b b b b b b b b b b b b b b b b b b b
during dressing?
b b
a. Have the client sit for as much dressing as possible.
b b b b b b b b b b
Page b4
, Nursing Diagnosis Handbook 12th Edition Ackley Test Bankb b b b b b b
1.
During the assessment of a client with left-sided weakness who is right-hand dominant, the nurse identifies that
b b b b b b b b b b b b b b b b
the client needs assistance with ambulation. Which of the following would be the most relevant defining
b b b b b b b b b b b b b b b b
characteristic for the nursing diagnosis of self-care deficit: bathing in this client?
b b b b b b b b b b b b
a. Inability to access bathroom b b b
b. Inability to dry body b b b
c. Inability to wash body b b b
d. Inability to regulate bath water b b b b
ANSWER: a b
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
b b b b b b b b b b b b b b b b b b b b b
bathing in the home, the nurse recognizes that there is a self-care deficit: bathing related to which of the
b b b b b b b b b b b b b b b b b b b
following?
b
a. Severe anxiety b
b. Environmental barriers b
c. Inability to perceive body part b b b b
d. Inability to perceive spatial relationships b b b b
ANSWER: b b
POINTS: 100
3. GRADESLAB.COM
The nurse is planning care for a client with severe dementia who becomes agitated during bathing. Which of the
b b b b b b b b b b b b b b b b b b
following outcomes would be most applicable for this client‟s nursing diagnosis of self-care deficit: bathing?
b b b b b b b b b b b b b b
a. Client will state satisfaction with ability to use adaptive devices to bathe.
b b b b b b b b b b b
b. Client will bathe self safely with minimal difficulty.
b b b b b b b
c. Client will bathe with assistance of caregiver as needed and report satisfaction.
b b b b b b b b b b b
d. Client will bathe with assistance without exhibiting defensive behaviors.
b b b b b b b b
ANSWER: d b
POINTS: 100
4.
The nurse is developing the plan of care for a client with dementia. Which of the following interventions should
b b b b b b b b b b b b b b b b b b
the nurse include to preserve the client‟s dignity during bathing?
b b b b b b b b b b
a. Provide privacy and encourage client participation.
b b b b b b
b. Give analgesics 30 minutes prior to bathing.
b b b b b b b
c. Provide client with a padded shower chair.
b b b b b b b
d. Use a prepackaged bath.
b b b b
ANSWER: a b
POINTS: 100
5.
Page b2
,In planning care for a client with dementia, the nurse should train caregivers bathing the client to use which of
b b b b b b b b b b b b b b b b b b b
Page b3
, the following behaviors to reduce aggression in the client?
b b b b b b b b
a. Avoid prior cueing for client.
b b b b b
b. Increase the speed of the bath.
b b b b b b
c. Prepare client before water spray.
b b b b b
d. Wash client‟s hair and face first.
b b b b b b
ANSWER: c b
POINTS: 100
6.
The nurse is planning care for a client who has severe arthritis and has very limited fine motor hand dexterity.
b b b b b b b b b b b b b b b b b b b
Which of the following would the nurse identify as the most relevant defining characteristic for this client for
b b b b b b b b b b b b b b b b b b
the nursing diagnosis of self-care deficit: dressing?
b b b b b b b
a. Inability to choose clothing
b b b b
b. Inability to maintain appearance
b b b b
c. Inability to use zippers
b b b b
d. Impaired ability to obtain clothing
b b b b b
ANSWER: c b
POINTS: 100
7.
The nurse is developing a plan of care for a client who has advanced dementia. The nurse recognizes that there
b b b b b b b b b b b b b b b b b b b
is a self-care deficit: dressing related to which of the following?
b b b b b b b b b b b
a. Anxiety b GRADESLAB.COM
b. Cognitive impairment
b b
c. Environmental barriers
b b
d. Weakness b
ANSWER: b
b b
POINTS: 100
b
8.
The nurse is planning care during rehabilitation for a client who experienced left-sided weakness following a
b b b b b b b b b b b b b b b
stroke. Which of the following outcomes would be the most desirable for this client‟s nursing diagnosis of self-
b b b b b b b b b b b b b b b b b b
care deficit: dressing?
b b b
a. Client will dress and groom self to optimal potential.
b b b b b b b b b
b. Client will identify types of assistive technology.
b b b b b b b
c. Client will be dressed by a caregiver.
b b b b b b b
d. Client will explore potential barriers to dressing.
b b b b b b b
ANSWER: a b
POINTS: 100
9.
A client had a recent fall and has residual dizziness. What action by the nurse best promotes safety for the client
b b b b b b b b b b b b b b b b b b b b
during dressing?
b b
a. Have the client sit for as much dressing as possible.
b b b b b b b b b b
Page b4
