A nursing student is writing a care plan for a newly admitted patient who has been diagnosed with a stroke. What major nursing diagnosis should be included in the patient's plan of care?
A) Fatigue related to abundance of family and visitors
B) Ineffective tissue perception
C) Alteration in fluid balance related to use of mannitol
D) Disturbed sensory perception related to medically imposed restrictions
Ans: D
Feedback: Based on the assessment data, the patient's major nursing diagnoses may include the following: Ineffective tissue perfusion (cerebral) related to bleeding or vasospasm; Disturbed sensory perception related to medically imposed restrictions (aneurysm precautions); Anxiety related to illness and/or medically imposed restrictions (aneurysm precautions). Ineffective tissue perception is not a nursing diagnosis. Mannitol would not be used in a hemorrhagic stroke patient. Visitors would be restricted so they would not cause fatigue in the patient.
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