Which of the following would be a priority goal for a patient with stroke-related sensory perception alterations?
1. protect from injury
2. promote increased tactile stimulation
3. increase perception of sensations
4. increase attention to hazards in the environment
1
Rationale: Because of the patient's inability to perceive sensations, such as touch, pressure, temperature, and proprioception, the nurse must be vigilant in assessing and intervening on behalf of the patient to prevent injury of all types. Promoting increased tactile stimulation would increase the patient's risk for injury. The nurse has no control over the patient's sensory perception, and, by increasing the patient's awareness of hazards in the environment, can heighten the patient's cognitive awareness but will not facilitate the patient in being able to perceive the hazards.
You might also like to view...
The enterostomal nurse advises the patient with a urinary diversion system on changing the collection appliance. The nurse informs the patient that the appliance will need to be changed:
A) Every day as part of morning care activities B) In the evening, prior to going to sleep for the night C) After every meal D) At a time that is convenient for the patient, but before it starts to leak
A patient with renal impairment who has been taking nitrofurantoin (Macrodantin) for a urinary tract infection telephones a nurse and describes the recent onset of "numbness and tingling" in the fingers and toes
The nurse should instruct the patient to a. discontinue the drug and come in for further evaluation. b. continue the drug and keep the hands and feet elevated when possible. c. check the color of the extremities and a pulse every 4 hours. d. collect a urine sample and bring it to the clinic.
A physician may telephone in an order for which of the following?
1. Morphine 2. Marijuana 3. Cocaine 4. Codeine
Exhaustion occurs if stress continues when which stage of the general adaptation syndrome is not successful?
a. Flight or fight b. Alarm c. Adaptation d. Arousal