The nurse is developing a plan of care for a patient who has had a stroke. Assessment findings include weakness in right upper and lower extremities, numbness in face, slurred speech, and headache

Question

Which of the following would best represent the etiology of the patient's gait and balance problems?
a.
Lack of muscle motor movement
b.
Decreased sensation to touch
c.
Inability to speak clearly
d.
Pain in back of head

Answer 1

ANS: A
The related factor in an actual nursing diagnosis needs to address the underlying etiology of the patient's problem expressed by the nursing diagnostic label rather than listing data that are defining characteristics. The decreased sensation to touch, inability to speak clearly, and pain in the back of the head are only reiterations of the defining characteristics (numbness in face, slurred speech, and headache).