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 C
Explanation
Choice A reason: This is an incorrect choice because professional shared governance is not a patient care action, but an organizational model that empowers nurses and other health care professionals to participate in decision making and policy development within their practice settings¹.
Choice B reason: This is an incorrect choice because nursing care delivery model is not a patient care action, but a framework that defines how nursing care is organized, coordinated, and delivered to the patients. Examples of nursing care delivery models include primary nursing, team nursing, and case management².
Choice C reason: This is the correct choice because interprofessional communication is a patient care action that involves exchanging information, ideas, and feedback among health care professionals from different disciplines who work together to provide comprehensive care for the patients. Interprofessional communication enhances collaboration, quality, and safety of care³.
Choice D reason: This is an incorrect choice because continuing staff education is not a patient care action, but a professional development activity that involves updating and enhancing the knowledge and skills of the health care staff through formal or informal learning opportunities. Continuing staff education improves the competence and performance of the staff.
Correct Answer is C
Explanation
Choice A reason: This is incorrect. Neuropathy due to uncontrolled diabetes is not an example of nociceptive pain. Neuropathy is a type of neuropathic pain, which is pain that is caused by damage or dysfunction of the nervous system. It can cause sensations of numbness, tingling, burning, or shooting pain in the affected area. It is not related to tissue injury or inflammation.
Choice B reason: This is incorrect. Phantom pain after amputation of a limb is not an example of nociceptive pain. Phantom pain is a type of neuropathic pain, which is pain that is felt in a body part that is no longer present. It can be triggered by memories, emotions, or stimuli. It is not related to tissue injury or inflammation.
Choice C reason: This is correct. Pain from rheumatoid arthritis joint damage is an example of nociceptive pain. Nociceptive pain is pain that is caused by tissue injury or inflammation. It can be triggered by mechanical, thermal, or chemical stimuli. It can cause sensations of aching, throbbing, or stabbing pain in the affected area.
Choice D reason: This is incorrect. Chronic nerve pain after shingles infection is not an example of nociceptive pain. Chronic nerve pain is a type of neuropathic pain, which is pain that is caused by damage or dysfunction of the nervous system. It can be caused by a viral infection, such as shingles, that affects the nerve fibers. It can cause sensations of burning, itching, or electric pain in the affected area. It is not related to tissue injury or inflammation.
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