Situation: A 68-year-old man is on the medical ward on day 4 after an ischemic stroke in the right cerebral hemisphere. He did not receive reperfusion therapy. He has left-sided weakness, is alert, and has hypertension. He passed a bedside swallow screen yesterday. At lunch, the nurse notices that he has eaten only the food on the right half of his plate and says he is finished. When the plate is turned around, he eats the rest. Confrontation testing earlier today showed full visual fields in both eyes. Which problem BEST explains this finding?

Failing to attend to one side of space while the visual fields are intact is unilateral neglect, typical of a right-hemisphere stroke, which disturbs spatial perception. Homonymous hemianopia is loss of the same half of the visual field in both eyes, which the confrontation test did not show. He ate the rest once the food was moved into the space he attends to, so neither satiety nor language comprehension explains the finding.

Core concept The patient eats only the right half of the plate despite intact visual fields on confrontation testing. This pattern is best explained by unilateral neglect, a disorder of spatial attention rather than vision itself.

Why it is not hemianopia Left homonymous hemianopia is a visual field deficit in which the same half of the visual field is lost in both eyes. If the patient had this condition, the confrontation test would have detected the field cut. In this case, the fields were full, so the problem is not that the patient cannot see the left side; it is that the brain does not attend to or process that side of space. Intact visual fields with failure to attend to one side of space is the defining distinction between neglect and hemianopia.

Pathophysiology of unilateral neglect Unilateral neglect most often follows damage to the right cerebral hemisphere, particularly the right parietal lobe and its connections. The right hemisphere directs attention to both the left and right sides of space, whereas the left hemisphere directs attention primarily to the right side. When the right hemisphere is injured, the left hemisphere can still attend to the right side, but the left side of space receives no attentional drive. The result is that the patient ignores or fails to respond to stimuli on the left side even though primary sensory pathways remain intact. This explains why the patient ate only the food on the right half of the plate. When the plate was turned around, the food was relocated into the right side of his attentional space, and he ate it. The food itself had not changed; only its position relative to his attended space changed.

Why the other options do not fit Early satiety from post-stroke depression would not explain why the patient resumed eating when the plate was rotated. If he were truly full or lacked appetite, moving the food would not restore intake. Receptive (Wernicke) aphasia is a language comprehension deficit associated with left-hemisphere lesions, not a right-hemisphere stroke. The patient is alert and followed the situation appropriately; he did not misunderstand instructions. The behavior is spatial, not linguistic.

Clinical assessment distinction

Feature	Unilateral neglect	Homonymous hemianopia
Primary deficit	Attention to one side of space	Vision loss in half of each visual field
Confrontation testing	Often normal	Detects field cut
Awareness of deficit	Usually absent (anosognosia)	May be aware and compensate by turning head
Typical lesion	Right hemisphere, especially parietal	Optic tract, optic radiation, or occipital cortex
Mealtime behavior	Eats one side of plate; improves when plate is turned	May also miss one side but does not improve simply by turning the plate unless the head is turned

Key point! The plate-turning response is a classic bedside indicator of neglect. In hemianopia, simply rotating the plate does not help unless the patient also turns the head or eyes to bring the food into the seeing field. In neglect, moving the stimulus into the attended side of space is sufficient.

Nursing relevance Unilateral neglect is recognized as a nursing diagnosis and requires active nursing assessment and intervention ^[2]. Neglect affects up to 80% of right-hemisphere stroke survivors and is a strong predictor of poor rehabilitation outcomes and prolonged hospitalization ^[3]. Because neglect involves personal, peripersonal, and extrapersonal space, assessment should not rely on a single test ^[1]. Nurses can observe functional behaviors such as eating, grooming, and wheelchair navigation to detect neglect that paper-and-pencil tests may miss. Interventions include placing food, call bells, and personal items on the attended side initially, then gradually encouraging scanning of the neglected side. Early identification of neglect is essential because it affects safety, self-care, and rehabilitation participation.