Which is the most appropriate nursing diagnosis for a patient who has a severe right-sided stroke with left-sided hemiplegia? The patient uses the right extremities well but does not realize that the left arm and leg even exist.
Unilateral neglect related to brain tissue damage after right-sided stroke
Ineffective denial related to inability to accept paralysis of left arm and leg
Deficient knowledge related to presence of paralyzed left arm and leg
Noncompliance related to inability to follow directions to use left arm and leg
The Correct Answer is A
Choice A reason: This is correct. Unilateral neglect is a condition where the patient fails to attend to or respond to stimuli on the opposite side of the brain lesion. It can affect the patient's perception, attention, memory, and motor function. It can also impair the patient's safety, self-care, and quality of life. The patient may not recognize the existence of the paralyzed limbs, ignore them, or deny their ownership.
Choice B reason: This is incorrect. Ineffective denial is a condition where the patient consciously or unconsciously refuses to acknowledge the reality of a situation that is too threatening or overwhelming. It can interfere with the patient's coping and adaptation. The patient may reject the diagnosis, prognosis, or treatment of the condition. However, this is not the case for the patient with unilateral neglect, who is not aware of the paralysis, rather than refusing to accept it.
Choice C reason: This is incorrect. Deficient knowledge is a condition where the patient lacks or misinterprets information about a topic related to health or illness. It can affect the patient's decision-making, compliance, and outcomes. The patient may have inaccurate or incomplete understanding of the causes, consequences, or management of the condition. However, this is not the main problem for the patient with unilateral neglect, who is not able to process or attend to the information, rather than lacking it.
Choice D reason: This is incorrect. Noncompliance is a condition where the patient does not or is unable to follow the prescribed or agreed-upon plan of care. It can result from various factors, such as lack of motivation, resources, support, or understanding. The patient may not adhere to the recommendations, instructions, or goals of the treatment. However, this is not the primary issue for the patient with unilateral neglect, who is not capable of performing the tasks, rather than unwilling to do so.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is an inappropriate statement for the nurse to include in the description of the incident because it is subjective, biased, and disrespectful. The nurse should not make judgments or assumptions about the patient's personality or behavior, but rather report the facts and observations of the situation.
Choice B reason: This is an inappropriate statement for the nurse to include in the description of the incident because it is irrelevant, speculative, and accusatory. The nurse should not blame or criticize the nurse assistant's performance, but rather focus on the patient's condition and the actions taken to prevent or manage the fall.
Choice C reason: This is an inappropriate statement for the nurse to include in the description of the incident because it is uncertain, hypothetical, and unprofessional. The nurse should not use words like "probably" or "maybe" that indicate a lack of clarity or certainty, but rather state the facts and evidence of the situation.
Choice D reason: This is an appropriate statement for the nurse to include in the description of the incident because it is objective, factual, and concise. The nurse should report the patient's location, status, and environment at the time of the fall, and the possible cause or contributing factors of the fall.
Correct Answer is A
Explanation
Choice A reason: This is the correct choice because the nurse checks if the hospital policy allows the licensed practical nurse to perform venipuncture before delegating the task is an action that demonstrates the concept of right supervision. Right supervision is one of the five rights of delegation, which are the principles that guide the nurse to delegate tasks safely and effectively. Right supervision means that the nurse provides appropriate guidance and monitoring of the delegated task and evaluates the outcomes³. By checking the hospital policy, the nurse ensures that the task is within the scope of practice and competency of the licensed practical nurse and that the delegation is consistent with the standards of care.
Choice B reason: This is an incorrect choice because the nurse confirms that the patient’s urine output is entered into the medical record by the nursing assistant by the end of the shift is not an action that demonstrates the concept of right supervision. Right supervision is one of the five rights of delegation, which are the principles that guide the nurse to delegate tasks safely and effectively. Right supervision means that the nurse provides appropriate guidance and monitoring of the delegated task and evaluates the outcomes³. By confirming the documentation, the nurse is performing a quality check, but not providing supervision of the delegated task.
Choice C reason: This is an incorrect choice because the nurse ensures that the scale is accurate before directing the nursing assistant to obtain the patient’s weight is not an action that demonstrates the concept of right supervision. Right supervision is one of the five rights of delegation, which are the principles that guide the nurse to delegate tasks safely and effectively. Right supervision means that the nurse provides appropriate guidance and monitoring of the delegated task and evaluates the outcomes³. By ensuring the accuracy of the scale, the nurse is preparing the equipment, but not providing supervision of the delegated task.
Choice D reason: This is an incorrect choice because the nurse directs the nursing assistant to ambulate the patient at least 20 feet in the hallway using the gait belt before lunch is not an action that demonstrates the concept of right supervision. Right supervision is one of the five rights of delegation, which are the principles that guide the nurse to delegate tasks safely and effectively. Right supervision means that the nurse provides appropriate guidance and monitoring of the delegated task and evaluates the outcomes³. By directing the nursing assistant, the nurse is assigning the task, but not providing supervision of the delegated task.
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