The nurse is assessing a patient who has a closed head injury and showing symptoms of confusion, drowsiness, and unequal pupils. Which of the following nursing diagnoses takes priority?


• The patient is showing signs of increased intracranial pressure, which means the most important nursing diagnosis is altered cerebral tissue perfusion 

• Increased ICP presents a life-threatening situation because of the pressure on vital brain structures. Early signs include a decrease in LOC, confusion, pupillary changes, headache, and vomiting. A patent airway and adequate ventilation must be ensured to improve cerebral tissue perfusion and to decrease ICP

• Incorrect: Altered level of cognitive function occurs due to increased ICP, but this is not a priority nursing diagnosis 

• Incorrect: There can be risk for injury but it is not as important as altered cerebral tissue perfusion because if cerebral perfusion is maximized, injury risk will be lowered 

• Incorrect: Sensory perceptual deficit is related to increased ICP which can be corrected once the ICP is reduced

Visit our website for other NCLEX topics now!