CDM Final Exam NCLEX Summer 2023/ 95
Questions and Answered/verified/ Graded A+
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 - -Inability to use zippers- With limited fine motor
dexterity in the hands, the client would most likely have trouble with using zippers, an
action that requires fine motor skills. There is no information that suggests the client is
unable to choose clothing, maintain appearance, or obtain clothing.
-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 - -Cognitive impairment- A client with advanced dementia has significant
cognitive impairment that could hinder dressing. There is no information about the
client having anxiety, weakness, or environmental barriers that make dressing difficult.
-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. - -Client will dress and groom self to
optimal potential- Dressing and grooming oneself shows the most independence of all
the options and therefor is the most desirable outcome. Identifying asistive technology
and exploring barriers to dressing assists in developing independence. Being dressed by
a caregiver is the least optimal choice as it shows maximal dependence on others.
-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. - -Have the client sit for as much
dressing as possible- For safety, a patient with dizziness and a history of falls should sit
for as much of dressing as possible as this activity can be tiring. Using a gait belt does
help prevent falls, but sitting is a better option. Holding the bed with one hand limits the
amount of self-dressing the client can do. The nurse performing most of the dressing
does not help the client gain or maintain independence.
-The nurse is teaching a client who has right sided weakness due to a stroke methods
for easier dressing. Which of 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. - -Dress the affected side first- Dressing the affected side
allows for easier manipulation of the client's clothing. A client with weakness may prefer
,to sit during dressing. Machine-based prompting is helpful for clients with cognitive
problems. Clothes that fasten in the back are more difficult to manipulate.
-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 - -Musculoskeletal impairment- The musculoskeletal
impairment secondary to a surgical procedure on the dominant side is the most
appropriate defining characteristic for this client's diagnosis. There is no indication that
the client is experiencing environmental barriers, neuromuscular impairment, or
perceptual impairment.
-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
Impaired ability to manipulate food in mouth - -Inability to bring food to mouth- While
all options are possible defining characteristics for this diagnosis, the severe hand
tremors would limit this client's ability to bring food from a plate or bowl to the mouth.
-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. - -Client will feed self safely- The
client's frequent cough after a stroke can indicate aspiration. Patient safety is a high
priority. The most optimal goal for the client is to be able to self-feed safely, without
aspiration or choking. The client may or may not need to identify assistive technology
and use adaptive utensils. Exploring barriers to feeding is also useful, but is not as
optimal an outcome as being able to self-feed safely.
-The nurse is providing a training session for the staff who participates in assisting
clients with eating. Which of the 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
42 minutes - -42 Minutes- A recent research study showed that allowing clients at risk
for weight loss an average of 42 minutes to eat meals was associated with better oral
intake and weight gain. The other timeframes are too short.
-The nurse is planning care for a client receiving a tube feeding. Which one of the
following interventions for the client should the nurse include for safety to help prevent
aspiration pneumonia?
Swab mouth once each shift with foam toothettes.
Provide regular oral care using toothbrush.
Avoid oral care to reduce oral secretions
Apply moisturizer to lips every 4 hours. - -Provide regular oral care using toothbrush-
Clients on tube feedings have been found to have poorer oral care than those not on tube
feedings, leading to an increased incidence of aspiration pneumonia. Using foam
Questions and Answered/verified/ Graded A+
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 - -Inability to use zippers- With limited fine motor
dexterity in the hands, the client would most likely have trouble with using zippers, an
action that requires fine motor skills. There is no information that suggests the client is
unable to choose clothing, maintain appearance, or obtain clothing.
-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 - -Cognitive impairment- A client with advanced dementia has significant
cognitive impairment that could hinder dressing. There is no information about the
client having anxiety, weakness, or environmental barriers that make dressing difficult.
-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. - -Client will dress and groom self to
optimal potential- Dressing and grooming oneself shows the most independence of all
the options and therefor is the most desirable outcome. Identifying asistive technology
and exploring barriers to dressing assists in developing independence. Being dressed by
a caregiver is the least optimal choice as it shows maximal dependence on others.
-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. - -Have the client sit for as much
dressing as possible- For safety, a patient with dizziness and a history of falls should sit
for as much of dressing as possible as this activity can be tiring. Using a gait belt does
help prevent falls, but sitting is a better option. Holding the bed with one hand limits the
amount of self-dressing the client can do. The nurse performing most of the dressing
does not help the client gain or maintain independence.
-The nurse is teaching a client who has right sided weakness due to a stroke methods
for easier dressing. Which of 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. - -Dress the affected side first- Dressing the affected side
allows for easier manipulation of the client's clothing. A client with weakness may prefer
,to sit during dressing. Machine-based prompting is helpful for clients with cognitive
problems. Clothes that fasten in the back are more difficult to manipulate.
-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 - -Musculoskeletal impairment- The musculoskeletal
impairment secondary to a surgical procedure on the dominant side is the most
appropriate defining characteristic for this client's diagnosis. There is no indication that
the client is experiencing environmental barriers, neuromuscular impairment, or
perceptual impairment.
-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
Impaired ability to manipulate food in mouth - -Inability to bring food to mouth- While
all options are possible defining characteristics for this diagnosis, the severe hand
tremors would limit this client's ability to bring food from a plate or bowl to the mouth.
-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. - -Client will feed self safely- The
client's frequent cough after a stroke can indicate aspiration. Patient safety is a high
priority. The most optimal goal for the client is to be able to self-feed safely, without
aspiration or choking. The client may or may not need to identify assistive technology
and use adaptive utensils. Exploring barriers to feeding is also useful, but is not as
optimal an outcome as being able to self-feed safely.
-The nurse is providing a training session for the staff who participates in assisting
clients with eating. Which of the 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
42 minutes - -42 Minutes- A recent research study showed that allowing clients at risk
for weight loss an average of 42 minutes to eat meals was associated with better oral
intake and weight gain. The other timeframes are too short.
-The nurse is planning care for a client receiving a tube feeding. Which one of the
following interventions for the client should the nurse include for safety to help prevent
aspiration pneumonia?
Swab mouth once each shift with foam toothettes.
Provide regular oral care using toothbrush.
Avoid oral care to reduce oral secretions
Apply moisturizer to lips every 4 hours. - -Provide regular oral care using toothbrush-
Clients on tube feedings have been found to have poorer oral care than those not on tube
feedings, leading to an increased incidence of aspiration pneumonia. Using foam
