Which assessment finding indicates to the nurse that the patient is experiencing difficulty with proprioception?

The patient must hold on to the railing when ambulating in the hallway.

The patient must add extra seasoning to food in order for it to have any flavor.

The patient suffered a first-degree burn when a heating pad was left on too long.

The patient did not smell smoke even though the smoke detector was alarming.

Answer and Explanation

The Correct Answer is A

Choice A reason: This is correct. The patient must hold on to the railing when ambulating in the hallway indicates that the patient is experiencing difficulty with proprioception. Proprioception is the body's ability to sense its own position, movement, and spatial orientation. It helps the patient maintain balance and coordination. If the patient has impaired proprioception, they may feel unsteady or fall when walking without support.

Choice B reason: This is incorrect. The patient must add extra seasoning to food in order for it to have any flavor does not indicate that the patient is experiencing difficulty with proprioception. This may indicate that the patient has a reduced sense of taste, which can be caused by various factors, such as aging, medication, infection, or smoking. It does not affect the patient's perception of their body or movement.

Choice C reason: This is incorrect. The patient suffered a first-degree burn when a heating pad was left on too long does not indicate that the patient is experiencing difficulty with proprioception. This may indicate that the patient has a reduced sense of pain or temperature, which can be caused by nerve damage, diabetes, or spinal cord injury. It does not affect the patient's perception of their body or movement.

Choice D reason: This is incorrect. The patient did not smell smoke even though the smoke detector was alarming does not indicate that the patient is experiencing difficulty with proprioception. This may indicate that the patient has a reduced sense of smell, which can be caused by nasal congestion, allergy, infection, or head injury. It does not affect the patient's perception of their body or movement.

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Correct Answer is A

Explanation

Choice A reason: This is the correct choice because accountability is the nursing care concept that is demonstrated when the nurse takes the time to correct assessment information that was entered for the wrong patient. Accountability refers to the expectation and requirement to report and explain the actions taken and the results achieved. The nurse is accountable for the accuracy and completeness of the documentation and for the quality and safety of the patient care⁴. By correcting the assessment information, the nurse demonstrates accountability for their own mistake and prevents potential harm to the patient.

Choice B reason: This is an incorrect choice because responsibility is not the nursing care concept that is demonstrated when the nurse takes the time to correct assessment information that was entered for the wrong patient. Responsibility refers to the obligation and duty to perform the assigned tasks and achieve the desired results. The nurse is responsible for conducting and documenting the assessment and for providing appropriate care for the patient⁴. By correcting the assessment information, the nurse is not fulfilling their responsibility, but rather rectifying their error.

Choice C reason: This is an incorrect choice because empowerment is not the nursing care concept that is demonstrated when the nurse takes the time to correct assessment information that was entered for the wrong patient. Empowerment refers to the ability and right of individuals or groups to make their own decisions without interference from others. The nurse is empowered to use their own judgment and expertise to solve problems and improve performance⁴. By correcting the assessment information, the nurse is not exercising their empowerment, but rather admitting their fault.

Choice D reason: This is an incorrect choice because delegation is not the nursing care concept that is demonstrated when the nurse takes the time to correct assessment information that was entered for the wrong patient. Delegation refers to the process of assigning tasks or activities to other staff members based on their scope of practice, competence, and availability. The nurse is responsible for delegating tasks safely and effectively and for supervising and evaluating the delegated staff⁴. By correcting the assessment information, the nurse is not delegating any task, but rather correcting their own work.

A. Takes metoprolol to treat hypertension. B. Takes docusate sodium for constipation. C. Takes acetaminophen for osteoarthritis pain. D. Takes insulin glulisine for type 1 diabetes. E. Takes prednisone for multiple sclerosis.

Correct Answer is ["A","D","E"]

Explanation

Choice A reason: This is correct. Taking metoprolol to treat hypertension can put the patient at high risk for development of vision problems. Metoprolol is a beta-blocker medication that can lower the blood pressure and heart rate. It can also reduce the blood flow to the eyes and cause dry eyes, blurred vision, or eye irritation.

Choice B reason: This is incorrect. Taking docusate sodium for constipation does not put the patient at high risk for development of vision problems. Docusate sodium is a stool softener medication that can ease the passage of hard stools. It does not have any direct effect on the eyes or vision.

Choice C reason: This is incorrect. Taking acetaminophen for osteoarthritis pain does not put the patient at high risk for development of vision problems. Acetaminophen is a pain reliever medication that can reduce inflammation and fever. It does not have any significant impact on the eyes or vision.

Choice D reason: This is correct. Taking insulin glulisine for type 1 diabetes can put the patient at high risk for development of vision problems. Insulin glulisine is a fast-acting insulin medication that can lower the blood sugar level. It can also cause fluctuations in the fluid balance and pressure in the eyes, leading to blurred vision, cataracts, glaucoma, or diabetic retinopathy.

Choice E reason: This is correct. Taking prednisone for multiple sclerosis can put the patient at high risk for development of vision problems. Prednisone is a corticosteroid medication that can suppress the immune system and reduce inflammation. It can also increase the intraocular pressure and cause cataracts, glaucoma, or optic nerve damage.

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Which assessment finding indicates to the nurse that the patient is experiencing difficulty with proprioception?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing care concept is demonstrated when the nurse takes the time to correct assessment information that was entered for the wrong patient?

Correct Answer is A

Explanation

Which assessment findings put the patient at high risk for development of vision problems? (Select all that apply)

Correct Answer is ["A","D","E"]

Explanation

The nurse is caring for a patient who has been unable to have a bowel movement for the last 4 days after taking prescribed narcotic pain medication. Which nursing diagnosis is appropriate for this patient?

The nurse is caring for a patient whose temperature has dropped from 102.4°F to 99.4°F. The nurse notes that the patient’s face is flushed. What is the reason for this assessment finding?

The nurse is caring for a patient who took 60 acetaminophen tablets. Which resource will the nurse contact for treatment guidelines when the patient arrives in the emergency room?

Which action by the nurse demonstrates the concept of nurse autonomy?

Which technique will provide the most accurate measurement of the patient’s core temperature?

Which assessment finding leads the nurse to add risk for poisoning to the patient’s care plan?

A patient’s blood pressure suddenly drops from 132/82 to 104/52. The nurse notes that the patient’s skin is pale and the patient appears ready to faint. What is the priority action of the nurse?

Which is the nurse’s first response when a patient smokes in the hospital bathroom and starts a fire?