CDM FINAL EXAM NCLEX QS And As

CDM FINAL EXAM NCLEX Q’S And A’s

Self Care Deficit: Dressing

1.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?a.Inability to choose clothing b.Inability to maintain appearance c.Inability to use zippers d.Impaired ability to obtain clothing 2.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?a.Anxiety b.Cognitive impairment c.Environmental barriers d.Weakness 3.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?

a.Client will dress and groom self to optimal potential.b.Client will identify types of assistive technology.c.Client will be dressed by a caregiver.d.Client will explore potential barriers to dressing.

4.A client had a recent fall and has residual dizziness. What action by the nurse best promotes safety for the client during dressing?a.Have the client sit for as much dressing as possible.b.Perform the majority of dressing for the client.c.Teach the client to hold the bed with one hand.d.Use a gait belt in case the patient falls during dressing.

5.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?a.Stand while dressing.b.Use clothing that fastens in the back.c.Use smart machine-based prompting.d.Dress the affected side first.

Self Care Deficit: Feeding

6.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?

a.Inability to cook food b.Inability to chew food c.Inability to bring food to mouth d.Impaired ability to manipulate food in mouth 7.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?a.Environmental barriers b.Musculoskeletal impairment c.Neuromuscular impairment d.Perceptual impairment 1 / 2

8.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?a.Client will feed self safely.b.Client will identify assistive technology for feeding.c.Client will use adaptive utensils for feeding.d.Client will explore potential barriers to feeding.

9.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?a.10 minutes b.13 minutes c.20 minutes d.42 minutes 10.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?a.Swab mouth once each shift with foam toothettes.b.Provide regular oral care using toothbrush.c.Avoid oral care to reduce oral secretions d.Apply moisturizer to lips every 4 hours.

Self Care Deficit: Toileting

11.During assessment the nurse identifies that a client needs assistance with ambulation. Which of the following would the nurse identify as the most relevant defining characteristic for this client’s

nursing diagnosis Self-Care Deficit: Toileting?

a.Inability to manipulate clothing for toileting b.Inability to get to toilet or commode c.Inability to wash hands after toileting d.Inability to carry out proper toilet hygiene 12.The nurse is developing a plan of care for a client who uses a wheelchair and requires toileting assistance. The nurse recognizes that there is a Self-Care Deficit: Toileting related to which of the following?a.Impaired transfer ability b.Environmental factors c.Fatigue d.Decreased motivation 13.The nurse is planning care for a client who experienced a traumatic amputation of the right arm.Which of the following outcomes would be most applicable for this client’s nursing diagnosis of

Self-Care Deficit: Toileting?

a.Client will toilet safely.b.Client will state satisfaction with ability to use adaptive devices for toileting.c.Client will toilet with assistance of caregiver.d.Client will wear adult incontinence briefs for safety 14.The nurse is planning to place a client with a fractured hip on a bed pan. Which one of the following interventions has research shown would be most effective in reducing the client’s anxiety about its use?a.Placing waterproof pads on bed.b.Provide analgesics 30 minutes after bed pan use.c.Warm bedpan with hot water.d.Discuss use of bed pan with client prior to its use.

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