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.

Choice A reason: This is an incorrect choice because the patient’s core temperature has not dropped too low. The normal body temperature range is 97.7°F to 99.5°F¹. The patient’s temperature is still within this range, although it has decreased from a feverish level.

Choice B reason: This is the correct choice because vasodilation is the process of widening the blood vessels to increase blood flow and heat loss². This is a natural response of the body to lower the temperature when it is too high. Vasodilation can cause the skin to appear flushed and feel warm to the touch³.

Choice C reason: This is an incorrect choice because the patient is not exhausted from shivering. Shivering is another mechanism of the body to increase the temperature when it is too low². Shivering involves involuntary muscle contractions that generate heat³. The patient’s temperature is not too low, so shivering is not likely to occur.

Choice D reason: This is an incorrect choice because the patient’s infection has not spread to the bloodstream. A bloodstream infection, or sepsis, is a serious condition that can cause a high fever, not a low one. Sepsis can also cause other symptoms, such as chills, rapid breathing, and confusion. The patient’s temperature has dropped, not increased, and there is no evidence of sepsis.

Choice A reason: This is an incorrect choice because a patient with chronic viral conjunctivitis would not benefit from the use of lubricant eye ointment. Conjunctivitis is an inflammation of the conjunctiva, which is the thin membrane that covers the white part of the eye and the inner surface of the eyelid. Viral conjunctivitis is caused by a virus, such as adenovirus or herpes simplex virus, and it can cause redness, itching, burning, tearing, or discharge in the eye. Lubricant eye ointment is a thick, greasy substance that can moisturize and protect the eye, but it can also trap the virus and worsen the infection. The patient with viral conjunctivitis should use artificial tears or saline drops instead, and avoid sharing towels, cosmetics, or eye drops with others.

Choice B reason: This is the correct choice because a stroke patient whose right eye does not close fully would benefit from the use of lubricant eye ointment. A stroke is a sudden interruption of blood flow to the brain, which can cause damage to the brain cells and affect various functions, such as movement, sensation, speech, or vision. A stroke patient whose right eye does not close fully may have facial paralysis or weakness on the right side of the face, which can impair the ability to blink or close the eye. This can cause dryness, irritation, or injury to the eye, especially at night. Lubricant eye ointment can help to keep the eye moist and prevent corneal ulcers or infections. The patient may also need to wear an eye patch or tape the eye shut during sleep.

Choice C reason: This is an incorrect choice because a patient with an eye infection after swimming in a pond would not benefit from the use of lubricant eye ointment. An eye infection is an inflammation or infection of the eye or its structures, such as the cornea, the iris, or the eyelid. Swimming in a pond can expose the eye to various microorganisms, such as bacteria, fungi, or parasites, that can cause eye infections. Some examples are Acanthamoeba keratitis, which is a rare but serious infection of the cornea caused by a parasite, or Pseudomonas aeruginosa, which is a common cause of bacterial conjunctivitis. Lubricant eye ointment is not effective against these microorganisms, and it can also interfere with the penetration of antibiotic or antifungal eye drops. The patient with an eye infection after swimming in a pond should seek medical attention and use the prescribed eye drops as directed.

Choice D reason: This is an incorrect choice because a patient who has extended-wear contact lenses in place would not benefit from the use of lubricant eye ointment. Extended-wear contact lenses are soft lenses that can be worn continuously for up to 30 days and nights, without the need to remove them for cleaning or disinfection. However, extended-wear contact lenses can increase the risk of eye infections, such as bacterial or fungal keratitis, which can cause severe pain, redness, blurred vision, or sensitivity to light. Lubricant eye ointment is not compatible with contact lenses, and it can damage the lens material or cause deposits or cloudiness on the lens. The patient who has extended-wear contact lenses in place should follow the instructions of the eye care provider and remove the lenses immediately if any signs of infection or irritation occur.