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TEST BANK FOR NURSING DIAGNOSIS HANDBOOK 12TH EDITION ACKLEY
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TEST BANK FOR NURSING DIAGNOSISHANDBOOK 12TH EDITION ACKLEY
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
•
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
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
• WeaknessANSWER: 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.
• Perform the majority of dressing for the client.
• Teach the client to hold the bed with one hand.
• Use a gait belt in case the patient falls during dressing.
ANSWER: a
POINTS: 100
10.
The nurse is teaching a client who has right-sided weakness due to a stroke methods for
easier dressing. Whichof the following interventions should the nurse include in this teaching
session?
• Stand while dressing.
• Use clothing that fastens in the back.
• Use smart machine-based prompting.
• Dress the affected side first.
ANSWER: d
POINTS: 100
11.
The nurse is planning care for a client who has Parkinson’s disease with severe hand
tremors. 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: feeding?
• Inability to cook food
• Inability to chew food
• Inability to bring food to mouth GRADESLAB.COM
• Impaired ability to manipulate food in mouth
, ANSWER: c
POINTS: 100
12.
The nurse is developing a plan of care for a right-hand dominant client who had a right
rotator cuff repair. The nurse recognizes that there is a self-care deficit: feeding related to
which of the following?
• Environmental barriers
• Musculoskeletal impairment
• Neuromuscular impairment
• Perceptual impairment
ANSWER: b
POINTS: 100
13.
The nurse is planning care for a client who is left-hand dominant and is experiencing right-
sided weakness and a frequent cough following a stroke. Which of the following outcomes
would be the most desirable for this
client’s nursing diagnosis of self-care deficit: feeding?
• Client will feed self safely.
• Client will identify assistive technology for feeding.
• Client will use adaptive utensils for feeding.
• Client will explore potential barriers to feeding.
ANSWER: a
POINTS: 100
14.
The nurse is providing a training session for the staff who participates in assisting clients with
eating. Which ofthe following timeframes should the nurse convey is needed per client meal
to promote weight gain in at-risk clients?
• 10 minutes
• 13 minutes
• 20 minutes
• 4
2
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