Nursing Diagnosis Handbook 12th Edition Ackley Test vv vv vv vv vv vv
Bank Latest Solution 2023/2024
vv vv vv vv
1.
During the assessment of a client with left-sided weakness who is right-hand dominant, the nurse identifies
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that the client needs assistance with ambulation. Which of the following would be the most relevant
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
defining characteristic for the nursing diagnosis of self-care deficit: bathing in this client?
vv vv vv vv vv vv vv vv vv vv vv vv vv
a. Inability to access bathroom vv vv vv
b. Inability to dry body vv vv vv
c. Inability to wash body vv vv vv
d. Inability to regulate bath water vv vv vv vv
ANSWER: a v v
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
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
for bathing in the home, the nurse recognizes that there is a self-care deficit: bathing related to which of
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
the following?
vv vv
a. Severe anxiety vv
b. Environmental barriers vv
c. Inability to perceive body part vv vv vv vv
d. Inability to perceive spatial relationships vv vv vv vv
ANSWER: b v v
POINTS: 100
3.
The nurse is planning care for a client with severe dementia who becomes agitated during bathing. Which
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
of the following outcomes would be most applicable for this client’s nursing diagnosis of self-care
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
deficit: bathing?
vv vv
a. Client will state satisfaction with ability to use adaptive devices to bathe.
vv vv vv vv vv vv vv vv vv vv vv
b. Client will bathe self safely with minimal difficulty.
vv vv vv vv vv vv vv
c. Client will bathe with assistance of caregiver as needed and report satisfaction.
vv vv vv vv vv vv vv vv vv vv vv
d. Client will bathe with assistance without exhibiting defensive behaviors.
vv vv vv vv vv vv vv vv
ANSWER: d v v
POINTS: 100
4.
The nurse is developing the plan of care for a client with dementia. Which of the following interventions
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
should the nurse include to preserve the client’s dignity during bathing?
vv vv vv vv vv vv vv vv vv vv vv
a. Provide privacy and encourage client participation.
vv vv vv vv vv
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,b. Give analgesics 30 minutes prior to bathing.
vv vv vv vv vv vv
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, c. Provide client with a padded shower chair.
vv vv vv vv vv vv
d. Use a prepackaged bath.
vv vv vv
ANSWER: a v v
POINTS: 100
5.
In planning care for a client with dementia, the nurse should train caregivers bathing the client to use
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
which of
vv vv
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, the following behaviors to reduce aggression in the client?
vv vv vv vv vv vv vv vv
a. Avoid prior cueing for client. vv vv vv vv
b. Increase the speed of the bath. vv vv vv vv vv
c. Prepare client before water spray. vv vv vv vv
d. Wash client’s hair and face first.vv vv vv vv vv
ANSWER: c v v
POINTS: 100
6.
The nurse is planning care for a client who has severe arthritis and has very limited fine motor hand
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
dexterity. Which of the following would the nurse identify as the most relevant defining characteristic
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
for this client for the nursing diagnosis of self-care deficit: dressing?
vv vv vv vv vv vv vv vv vv vv vv
a. Inability to choose clothing vv vv vv
b. Inability to maintain appearance vv vv vv
c. Inability to use zippers vv vv vv
d. Impaired ability to obtain clothing vv vv vv vv
ANSWER: c v v
POINTS: 100
7.
The nurse is developing a plan of care for a client who has advanced dementia. The nurse recognizes that
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
there is a self-care deficit: dressing related to which of the following?
vv vv vv vv vv vv vv vv vv vv vv vv
a. Anxiety
b. Cognitive impairment vv
c. Environmental barriers vv
d. Weakness
ANSWER: b
vv vv
POINTS: 100
vv
8.
The nurse is planning care during rehabilitation for a client who experienced left-sided weakness
vv vv vv vv vv vv vv vv vv vv vv vv vv
following a stroke. Which of the following outcomes would be the most desirable for this client’s nursing
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
diagnosis of self- care deficit: dressing?
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a. Client will dress and groom self to optimal potential.
vv vv vv vv vv vv vv vv
b. Client will identify types of assistive technology.
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c. Client will be dressed by a caregiver.
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d. Client will explore potential barriers to dressing.
vv vv vv vv vv vv
ANSWER: a v v
POINTS: 100
9.
A client had a recent fall and has residual dizziness. What action by the nurse best promotes safety for the
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
client during dressing?
vv vv vv
a. Have the client sit for as much dressing as possible.
vv vv vv vv vv vv vv vv vv
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Bank Latest Solution 2023/2024
vv vv vv vv
1.
During the assessment of a client with left-sided weakness who is right-hand dominant, the nurse identifies
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
that the client needs assistance with ambulation. Which of the following would be the most relevant
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
defining characteristic for the nursing diagnosis of self-care deficit: bathing in this client?
vv vv vv vv vv vv vv vv vv vv vv vv vv
a. Inability to access bathroom vv vv vv
b. Inability to dry body vv vv vv
c. Inability to wash body vv vv vv
d. Inability to regulate bath water vv vv vv vv
ANSWER: a v v
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
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
for bathing in the home, the nurse recognizes that there is a self-care deficit: bathing related to which of
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
the following?
vv vv
a. Severe anxiety vv
b. Environmental barriers vv
c. Inability to perceive body part vv vv vv vv
d. Inability to perceive spatial relationships vv vv vv vv
ANSWER: b v v
POINTS: 100
3.
The nurse is planning care for a client with severe dementia who becomes agitated during bathing. Which
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
of the following outcomes would be most applicable for this client’s nursing diagnosis of self-care
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
deficit: bathing?
vv vv
a. Client will state satisfaction with ability to use adaptive devices to bathe.
vv vv vv vv vv vv vv vv vv vv vv
b. Client will bathe self safely with minimal difficulty.
vv vv vv vv vv vv vv
c. Client will bathe with assistance of caregiver as needed and report satisfaction.
vv vv vv vv vv vv vv vv vv vv vv
d. Client will bathe with assistance without exhibiting defensive behaviors.
vv vv vv vv vv vv vv vv
ANSWER: d v v
POINTS: 100
4.
The nurse is developing the plan of care for a client with dementia. Which of the following interventions
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
should the nurse include to preserve the client’s dignity during bathing?
vv vv vv vv vv vv vv vv vv vv vv
a. Provide privacy and encourage client participation.
vv vv vv vv vv
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,b. Give analgesics 30 minutes prior to bathing.
vv vv vv vv vv vv
Page vv2
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, c. Provide client with a padded shower chair.
vv vv vv vv vv vv
d. Use a prepackaged bath.
vv vv vv
ANSWER: a v v
POINTS: 100
5.
In planning care for a client with dementia, the nurse should train caregivers bathing the client to use
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
which of
vv vv
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, the following behaviors to reduce aggression in the client?
vv vv vv vv vv vv vv vv
a. Avoid prior cueing for client. vv vv vv vv
b. Increase the speed of the bath. vv vv vv vv vv
c. Prepare client before water spray. vv vv vv vv
d. Wash client’s hair and face first.vv vv vv vv vv
ANSWER: c v v
POINTS: 100
6.
The nurse is planning care for a client who has severe arthritis and has very limited fine motor hand
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
dexterity. Which of the following would the nurse identify as the most relevant defining characteristic
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
for this client for the nursing diagnosis of self-care deficit: dressing?
vv vv vv vv vv vv vv vv vv vv vv
a. Inability to choose clothing vv vv vv
b. Inability to maintain appearance vv vv vv
c. Inability to use zippers vv vv vv
d. Impaired ability to obtain clothing vv vv vv vv
ANSWER: c v v
POINTS: 100
7.
The nurse is developing a plan of care for a client who has advanced dementia. The nurse recognizes that
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
there is a self-care deficit: dressing related to which of the following?
vv vv vv vv vv vv vv vv vv vv vv vv
a. Anxiety
b. Cognitive impairment vv
c. Environmental barriers vv
d. Weakness
ANSWER: b
vv vv
POINTS: 100
vv
8.
The nurse is planning care during rehabilitation for a client who experienced left-sided weakness
vv vv vv vv vv vv vv vv vv vv vv vv vv
following a stroke. Which of the following outcomes would be the most desirable for this client’s nursing
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
diagnosis of self- care deficit: dressing?
vv vv vv vv vv vv
a. Client will dress and groom self to optimal potential.
vv vv vv vv vv vv vv vv
b. Client will identify types of assistive technology.
vv vv vv vv vv vv
c. Client will be dressed by a caregiver.
vv vv vv vv vv vv
d. Client will explore potential barriers to dressing.
vv vv vv vv vv vv
ANSWER: a v v
POINTS: 100
9.
A client had a recent fall and has residual dizziness. What action by the nurse best promotes safety for the
vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv vv
client during dressing?
vv vv vv
a. Have the client sit for as much dressing as possible.
vv vv vv vv vv vv vv vv vv
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