A client has severe right-sided weakness and is unable to complete bathing and grooming inde-pendently. Based on this observation, the nurse identifies a nursing diagnosis of:
1. Powerlessness
2. Self-care deficit
3. Tissue integrity impairment
4. Knowledge deficit of hygiene practices
ANS: 2
The client who is unable to complete bathing and grooming independently has a nursing diagno-sis of self-care deficit. Being unable to complete bathing and grooming are not defining charac-teristics for the nursing diagnosis of powerlessness. Being unable to complete bathing and grooming are not defining characteristics for the nursing diagnosis of tissue integrity impairment. There is no indication this client has a knowledge deficit of hygiene practices.
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