The nurse notes that a patient is able to walk down steps without ...

[jman1234]

The nurse notes that a patient is able to walk down steps without having to look down at her feet. This finding is considered
 
  a. Optic reflex c. Labyrinthine sense
  b. Antigravity reflex d. Proprioception

Question 2

A client has a body temperature of 95F and exhibits slurred speech and poor coordination. Which of the following nursing diagnoses is the priority for the client at this time?
 
  1. Risk for Imbalanced Body Temperature
   2. Hypothermia
   3. Acute Confusion
   4. Disturbed Sensory Perception

[Brenm]

Answer to Question 1

D
The optic reflex is a visual sensation that affects posture by helping the person establish spatial relationships to surrounding objects. The antigravity reflex occurs when extensor muscles are stretched beyond a certain point and the stimulation causes a reflex contraction that counteracts the gravitational pull. The labyrinthine sense occurs when sensory organs in the ear activate impulses when the head is turned. Proprioception is the awareness of posture, movement, and changes in equilibrium and the knowledge of position, weight, and resistance of objects in relation to the body. An example of this is walking down the steps without looking at the feet.

Answer to Question 2

1. Risk for Imbalanced Body Temperature

Rationale:
The client is demonstrating signs of a mild reduction in body temperature. The nursing diagnosis appropriate at this time would be risk for imbalanced body temperature. A body temperature below 90F would indicate hypothermia. Confusion is a manifestation of mild hypothermia and not the priority nursing diagnosis. Sensory impairment may or may not be present in this client.

[jman1234]

Both answers were spot on, thank you once again

[Brenm]

Great! Please up vote