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

Altered cerebral tissue perfusion

Explanation

• The patient is showing signs of increased intracranial pressure (ICP), 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.

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