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Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning
Care, 12th Edition by Ackley Test Bank 2 / 4
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?
- Inability to access bathroom
- Inability to dry body
- Inability to wash body
- 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?
- Severe anxiety
- Environmental barriers
- Inability to perceive body part
- Inability to perceive spatial relationships
ANSWER: 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 following outcomes would be most applicable for this client’s nursing diagnosis of self-care deficit: bathing?
- Client will state satisfaction with ability to use adaptive devices to bathe.
- Client will bathe self safely with minimal difficulty.
- Client will bathe with assistance of caregiver as needed and report satisfaction.
- 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?
- Provide privacy and encourage client participation.
- Give analgesics 30 minutes prior to bathing.
- Provide client with a padded shower chair.
- Use a prepackaged bath.
ANSWER: a
POINTS: 100
5.In planning care for a client with dementia, the nurse should train caregivers bathing the client to use which of 3 / 4
the following behaviors to reduce aggression in the client?
- Avoid prior cueing for client.
- Increase the speed of the bath.
- Prepare client before water spray.
- Wash client’s hair and face first.
ANSWER: c
POINTS: 100
6.The nurse is planning care for a client who has severe arthritis and has very limited fine motor hand dexterity.Which of the following would the nurse identify as the most relevant defining characteristic for this client for
the nursing diagnosis of self-care deficit: dressing?
- Inability to choose clothing
- Inability to maintain appearance
- Inability to use zippers
- Impaired ability to obtain clothing
ANSWER: c
POINTS: 100
7.The nurse is developing a plan of care for a client who has advanced dementia. The nurse recognizes that there
is a self-care deficit: dressing related to which of the following?
- Anxiety
- Cognitive impairment
- Environmental barriers
- Weakness
ANSWER: b
POINTS: 100
GRADESLAB.COM
8.The nurse is planning care during rehabilitation for a client who experienced left-sided weakness following a stroke. Which of the following outcomes would be the most desirable for this client’s nursing diagnosis of self-
care deficit: dressing?
- Client will dress and groom self to optimal potential.
- Client will identify types of assistive technology.
- Client will be dressed by a caregiver.
- Client will explore potential barriers to dressing.
ANSWER: a
POINTS: 100
9.A client had a recent fall and has residual dizziness. What action by the nurse best promotes safety for the client during dressing?
- Have the client sit for as much dressing as possible.
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