Answer to Question 1
ANS: B
Readiness for enhanced self-care is evidenced by a patient expressing a desire to be independent in ADLs. Ineffective health maintenance is an inability to maintain health, hygiene self-care deficit indicates they are unable to perform hygiene, and disturbed body image relates to how they view their body.
Answer to Question 2
ANS: A
The Braden scale is used to determine risk for impaired skin integrity: The Glasgow is a coma scale, the Vanderbilt is a behavior scale, and the MMSE is the mini-mental exam to determine cognitive status.