NURSING DIAGNOSIS
HANDBOOK 12th
EDITION 2023\2024
1.
During the assessment of a client with left- sided weakness who is right hand dominant, the nurse
... [Show More] identifiees that
the client needs assistance with ambulation. Which of the following would be the most relevant defiening
characteristic for the nursing diagnosis of self care defiecit: 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.
Thee 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 defiecit: 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.
Thee 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 defiecit: bathing?
a. Client will state satisfaction with ability to use adaptive devices to bathe.
b. Client will bathe self safely with minimal difficculty.
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.
Thee 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
5.
In planning care for a client with dementia, the nurse should train caregivers bathing the client to use which of
2023/2024
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the following behaviors to reduce aggression in the client?
a. Avoid prior cueing for client.
b. Increase the speed of the bath.
c. Prepare client before water spray.
d. Wash client’s hair and face fierst.
ANSWER: c
POINTS: 100
6.
Thee nurse is planning care for a client who has severe arthritis and has very limited fiene motor hand dexterity.
Which of the following would the nurse identify as the most relevant defiening characteristic for this client for
the nursing diagnosis of self care defiecit: dressing?
a. Inability to choose clothing
b. Inability to maintain appearance
c. Inability to use zippers
d. Impaired ability to obtain clothing
ANSWER: c
POINTS: 100
7.
Thee nurse is developing a plan of care for a client who has advanced dementia. Thee nurse recognizes that there
is a self care defiecit: dressing related to which of the following?
a. Anxiety
b. Cognitive impairment
c. Environmental barriers
d. Weakness
ANSWER: b
POINTS: 100
8.
Thee 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 defiecit: dressing?
a. Client will dress and groom self to optimal potential.
b. Client will identify types of assistive technology.
c. Client will be dress [Show Less]