The nurse is planning care for a patient with a thrombotic stroke in the distribution of the right middle cerebral artery
Which of the following nursing diagnoses would be the priority for care in the acute phase of this disease process? 1. decreased intracranial adaptive capacity
2. altered nutrition: less than body requirements
3. altered cerebral tissue perfusion
4. total self-care deficit
3
Rationale: The priority for care in the early and acute phase of a thrombotic stroke is to maintain the effect perfusion to the area near the infarct, the penumbra. In this type of stroke, increased intracranial pressure is generally not a major concern; therefore, decreased intracranial adaptive capacity is not the priority. The patient may have self-care deficits but not total, and nutrition should be supported by the nurse and other members of the health care team.
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