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 nurse braids the patient’s long hair to prevent tangles is not an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Braiding the patient’s hair is a personal care task that does not require the nurse to use their own judgment or expertise.

Choice B reason: This is the correct choice because the nurse checks the policy manual before changing the central line dressing is an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Checking the policy manual before changing the central line dressing shows that the nurse is responsible for following the evidence-based guidelines and standards of practice for this procedure.

Choice C reason: This is an incorrect choice because the nurse counts the patient’s pulse before administering digoxin is not an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Counting the patient’s pulse before administering digoxin is a routine task that is prescribed by the physician and does not involve the nurse’s own decision making.

Choice D reason: This is an incorrect choice because the nurse directs the nursing assistant to obtain the patient's weight is not an action that demonstrates the concept of nurse autonomy. Nurse autonomy refers to the ability and right of nurses to make independent decisions about patient care without interference from others. Directing the nursing assistant to obtain the patient's weight is a task that is delegated by the nurse and does not reflect the nurse’s own authority or initiative.

Choice A reason: This is correct. Teaching the patient to wear low-heeled, comfortable, supportive footwear at all times is the highest priority intervention for a patient with diabetic neuropathy who has lost sensation in both feet. This can prevent foot injuries, ulcers, and infections that can lead to amputation.

Choice B reason: This is incorrect. Encouraging the patient to participate in tai chi exercises to promote balance is a beneficial intervention for a patient with diabetic neuropathy who has lost sensation in both feet, but not the highest priority. Tai chi can improve muscle strength, coordination, and flexibility, but it does not protect the feet from injury.

Choice C reason: This is incorrect. Evaluating the patient's blood pressure for orthostatic hypotension is an important intervention for a patient with diabetic neuropathy who has lost sensation in both feet, but not the highest priority. Orthostatic hypotension is a condition where the blood pressure drops when the patient changes position, causing dizziness and fainting. It can be caused by autonomic neuropathy, which affects the nerves that control blood pressure and heart rate.

Choice D reason: This is incorrect. Instructing the patient to wear a medical alert bracelet that identifies risk for falls is a helpful intervention for a patient with diabetic neuropathy who has lost sensation in both feet, but not the highest priority. A medical alert bracelet can alert emergency personnel of the patient's condition and medications, but it does not prevent falls or foot injuries.