Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness (LOC). Which nursing diagnosis do they determine has the highest priority for the patient?
a. Impaired physical mobility related to weakness
b. Disturbed sensory perception related to brain injury
c. Risk for impaired skin integrity related to immobility
d. Risk for aspiration related to inability to protect airway
ANS: D
Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time.
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