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

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