Nclexrn Quiz: Acute Stroke Priority Actions And Care
20 questions · exam conditions
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Acute Stroke Priority Actions And CareQuestion 1 of 20

A 64-year-old client with type 2 diabetes, hypertension, and smoking history arrives to the emergency department 90 minutes after sudden onset of right leg weakness and difficulty speaking. Assessment: BP 178/94 mmHg, HR 96/min, RR 18/min, SpO2 95% on room air; blood glucose 42 mg/dL (normal 70–110). Which intervention should the nurse implement FIRST?

Prepare the client for immediate noncontrast head computed tomography
Administer intravenous dextrose per hypoglycemia protocol and reassess neurologic status
Administer aspirin after confirming the client can swallow safely
Obtain a detailed last-known-well time from family and document
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Nclexrn Quiz: Acute Stroke Priority Actions And Care

Practice Acute Stroke Priority Actions And Care in Nclexrn with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.

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This quiz focuses on Acute Stroke Priority Actions And Care, giving you a quick way to practice the rules, question types, and explanations that matter most for Nclexrn.

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Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.

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Question 1

A 64-year-old client with type 2 diabetes, hypertension, and smoking history arrives to the emergency department 90 minutes after sudden onset of right leg weakness and difficulty speaking. Assessment: BP 178/94 mmHg, HR 96/min, RR 18/min, SpO2 95% on room air; blood glucose 42 mg/dL (normal 70–110). Which intervention should the nurse implement FIRST?

  1. Prepare the client for immediate noncontrast head computed tomography
  2. Administer intravenous dextrose per hypoglycemia protocol and reassess neurologic status (correct answer)
  3. Administer aspirin after confirming the client can swallow safely
  4. Obtain a detailed last-known-well time from family and document
Explanation: This question tests prioritization and clinical judgment in acute stroke care. The priority framework uses ABCs and addresses reversible causes like hypoglycemia mimicking stroke. Administering intravenous dextrose per protocol and reassessing is the highest priority based on guidelines to correct hypoglycemia before further evaluation. Preparing for CT assumes stroke without ruling out mimics; aspirin is contraindicated until hemorrhage is excluded; obtaining last known well is important but secondary to treating low glucose. The decision-making principle is to treat hypoglycemia immediately as it can resolve symptoms. Guidelines mandate glucose check and correction in all suspected strokes. A transferable strategy is to always screen and correct metabolic abnormalities first in acute neuro presentations.

Question 2

A 70-year-old client with hypertension and hyperlipidemia presents to the emergency department 3 hours after sudden left-sided weakness and slurred speech began. Assessment: BP 212/110 mmHg, HR 78/min, RR 18/min, SpO2 96% on room air, blood glucose 102 mg/dL (normal 70–110). The provider writes orders for suspected acute ischemic stroke. The nurse should QUESTION which order related to stroke management?

  1. Keep the client nothing by mouth until a bedside swallow screen is completed
  2. Administer alteplase (tPA) now before obtaining head computed tomography (correct answer)
  3. Obtain a noncontrast head computed tomography STAT
  4. Draw labs including complete blood count and coagulation studies
Explanation: This question tests prioritization and clinical judgment in acute stroke care. The priority framework emphasizes time-sensitive interventions and verifying orders against evidence-based protocols. The nurse should question administering alteplase before CT, as guidelines require ruling out hemorrhage first to avoid catastrophic complications. Keeping NPO until swallow screen prevents aspiration but is standard; obtaining CT STAT is essential; drawing labs is routine for eligibility. The decision-making principle is safety in thrombolytic administration. American Heart Association guidelines contraindicate tPA without confirmatory imaging. A transferable strategy is to always verify imaging results before initiating high-risk therapies in suspected strokes.

Question 3

A 57-year-old client with hypertension and cocaine use history arrives to the emergency department 1 hour after sudden left-sided weakness and slurred speech. Assessment: BP 210/112 mmHg, HR 104/min, RR 20/min, SpO2 96% on room air; blood glucose 97 mg/dL (normal 70–110). What is the nurse's PRIORITY action?

  1. Activate stroke alert and prepare for immediate noncontrast head computed tomography (correct answer)
  2. Administer a sedative to decrease sympathetic stimulation and blood pressure
  3. Delay imaging until blood pressure is normalized to prevent hemorrhage
  4. Obtain a urine drug screen before initiating any stroke interventions
Explanation: This question tests prioritization and clinical judgment in acute stroke care. The priority framework emphasizes not delaying imaging despite comorbidities like drug use. Activating alert and preparing for CT is the highest priority based on guidelines to diagnose quickly regardless of BP. Administering sedative is not first-line; delaying for BP normalization risks time; drug screen is secondary. The decision-making principle is time-sensitive diagnosis. Guidelines allow imaging with high BP. A transferable strategy is to proceed with protocol activation even in complex cases like substance use.

Question 4

A 76-year-old client is 3 hours post-alteplase for ischemic stroke. The nurse notes the client is suddenly lethargic and has new right pupil dilation. Assessment: BP 204/110 mmHg, HR 60/min, RR 10/min, SpO2 94% on room air. What is the nurse's PRIORITY action?

  1. Provide fluids and encourage rest to treat possible dehydration
  2. Administer the next scheduled anticoagulant dose to prevent recurrent stroke
  3. Reassess neurologic status in 30 minutes to confirm the change
  4. Notify the provider/stroke team immediately and prepare for emergent head computed tomography (correct answer)
Explanation: This question tests prioritization and clinical judgment in acute stroke care. The priority framework monitors for post-tPA complications like increased intracranial pressure. Notifying the team and preparing for CT is the highest priority based on guidelines for signs of herniation or bleed. Administering anticoagulant risks worsening; reassessing delays; providing fluids assumes dehydration. The decision-making principle is rapid imaging for deterioration. Guidelines recommend emergent evaluation for pupil changes. A transferable strategy is to prioritize neuroimaging and escalation for any acute post-treatment neuro decline.

Question 5

A 73-year-old client with atrial fibrillation and hypertension is admitted for heart failure exacerbation. The nurse finds the client with new right-sided weakness and inability to speak; last known well was 15 minutes ago. Assessment: BP 166/90 mmHg, HR 120 irregular, RR 22/min, SpO2 93% on room air; blood glucose 106 mg/dL (normal 70–110). Which intervention should the nurse implement FIRST?

  1. Apply oxygen to maintain SpO2 at or above 94% and activate the stroke protocol (correct answer)
  2. Administer the scheduled diuretic to improve oxygenation and reduce confusion
  3. Obtain a complete set of intake and output data for the last 24 hours
  4. Request a physical therapy consult for new weakness
Explanation: This question tests prioritization and clinical judgment in acute stroke care. The priority framework integrates ABCs with stroke protocol activation. Applying oxygen and activating protocol is the highest priority based on guidelines to optimize perfusion and enable rapid treatment. Administering diuretic assumes heart failure cause; obtaining I&O is secondary; PT consult follows diagnosis. The decision-making principle is addressing hypoxia first. Guidelines recommend SpO2 >=94% in strokes. A transferable strategy is to correct oxygenation while initiating stroke response in hypoxic patients with neuro changes.

Question 6

A 56-year-old client with hypertension and migraines arrives to the emergency department 1 hour after sudden onset of severe headache, right-sided weakness, and slurred speech. Assessment: BP 198/108 mmHg, HR 72/min, RR 14/min, SpO2 98% on room air; blood glucose 99 mg/dL (normal 70–110). What is the nurse's PRIORITY action?

  1. Administer prescribed opioid analgesia for headache relief
  2. Activate stroke alert and prepare for immediate noncontrast head computed tomography (correct answer)
  3. Dim the lights and place the client in a quiet room to reduce migraine triggers
  4. Apply ice packs to the head and reassess pain in 30 minutes
Explanation: This question tests prioritization and clinical judgment in acute stroke care. The priority framework uses time-sensitive interventions for possible hemorrhagic stroke. Activating alert and preparing for CT is the highest priority based on guidelines to rule out bleed in severe headache with neuro deficits. Administering opioid is inappropriate without diagnosis; dimming lights assumes migraine; applying ice delays care. The decision-making principle is differentiating stroke types urgently. Guidelines prioritize imaging for thunderclap headaches. A transferable strategy is to treat severe headache with focal signs as potential hemorrhage and expedite diagnostics.

Question 7

A 71-year-old client received alteplase for acute ischemic stroke 2 hours ago. History includes hypertension and diabetes. The nurse notes oozing at the intravenous site and new gum bleeding. Assessment: BP 152/88 mmHg, HR 92/min, RR 18/min, SpO2 97% on room air; neurologic status unchanged from baseline. What is the nurse's PRIORITY action?

  1. Apply direct pressure to bleeding sites and notify the provider/stroke team of suspected bleeding complication (correct answer)
  2. Administer aspirin to prevent additional clot formation
  3. Encourage frequent tooth brushing to reduce gum bleeding
  4. Ambulate the client to prevent venous thromboembolism
Explanation: This question tests prioritization and clinical judgment in acute stroke care. The priority framework monitors for bleeding post-thrombolysis. Applying pressure and notifying the team is the highest priority based on guidelines for managing hemorrhage complications. Administering aspirin worsens bleeding; encouraging brushing irritates sites; ambulating risks falls. The decision-making principle is prompt intervention for coagulopathy signs. Guidelines advise stopping anticoagulants and supportive care. A transferable strategy is to inspect sites frequently and escalate any bleeding post-tPA.

Question 8

A 72-year-old client with atrial fibrillation, hypertension, and obesity is on a medical-surgical unit for pneumonia and suddenly becomes confused with new right-sided weakness. Last known well was 20 minutes ago. Assessment: BP 176/88 mmHg, HR 118 irregular, RR 20/min, SpO2 94% on 2 L nasal cannula, blood glucose 104 mg/dL (normal 70–110). What is the nurse's PRIORITY action?

  1. Notify the provider during rounds and continue to monitor neurologic status every 4 hours
  2. Activate the facility's rapid response/stroke protocol and prepare for emergent transport to imaging (correct answer)
  3. Administer the prescribed antibiotic early to prevent worsening infection-related delirium
  4. Reorient the client and obtain a urine specimen to evaluate for urinary tract infection
Explanation: This question tests prioritization and clinical judgment in acute stroke care. The priority framework involves recognizing inpatient stroke symptoms and activating rapid response for time-sensitive interventions. Activating the rapid response/stroke protocol and preparing for emergent imaging is the highest priority based on guidelines to ensure quick diagnosis and treatment. Notifying during rounds delays care; administering antibiotics assumes infection without evidence; and reorienting with urine collection addresses delirium but not acute stroke. The decision-making principle is to treat sudden neuro changes as stroke until proven otherwise. Hospital protocols emphasize immediate activation for last known well under 24 hours. A transferable strategy is to document last known well time and escalate care immediately for any new focal deficits in hospitalized patients.

Question 9

A 66-year-old client arrives to the emergency department 30 minutes after sudden onset of right arm weakness and difficulty speaking. History includes hypertension, hyperlipidemia, and obesity. Assessment: drooling, wet/gurgly voice, unable to handle oral secretions, oxygen saturation 89% on room air, RR 26/min, BP 170/94 mmHg, HR 102/min. What is the nurse's PRIORITY action for this client?

  1. Place the client in a high-Fowler position and suction oral secretions while applying oxygen (correct answer)
  2. Obtain a detailed medication history to determine eligibility for thrombolytic therapy
  3. Start an intravenous line and draw blood for coagulation studies
  4. Prepare the client for immediate noncontrast head computed tomography
Explanation: This question tests prioritization and clinical judgment in acute stroke care using the ABC priority framework. The priority is addressing airway compromise and hypoxia before proceeding with stroke evaluation. Placing the client in high-Fowler position, suctioning secretions, and applying oxygen (option A) is the highest priority because the client has signs of aspiration risk (drooling, wet voice, inability to handle secretions) and hypoxia (SpO2 89%). Option B (medication history) is important but not before stabilizing ABCs; option C (IV access) follows airway management; option D (CT scan) cannot safely proceed with an unstable airway. The guiding principle is that airway protection and oxygenation always take precedence over diagnostic procedures in acute care. The transferable strategy is to recognize aspiration risk in stroke patients and prioritize airway protection before pursuing time-sensitive stroke interventions.

Question 10

A 75-year-old client with a history of transient ischemic attacks, carotid stenosis, and hypertension arrives to the emergency department 30 minutes after sudden facial droop and inability to speak. Assessment: follows commands with right hand only, left arm flaccid, BP 158/86 mmHg, HR 82/min, RR 16/min, SpO2 98% on room air; blood glucose 92 mg/dL (normal 70–110). Which intervention should the nurse implement FIRST?

  1. Request a speech therapy consult to identify communication strategies for the client's impaired verbal expression
  2. Apply sequential compression devices to the client's lower extremities to prevent deep vein thrombosis during stroke care
  3. Teach the family about the expected stroke rehabilitation and recovery plan for the client's deficits
  4. Obtain the exact time the client was last known well and activate the stroke protocol (correct answer)
Explanation: Acute stroke care is time-based: the critical next step is to establish the exact time the client was last known well and to activate the stroke protocol, because thrombolysis and endovascular treatment decisions are calculated from that time. The blood glucose is normal and vital signs are stable, so the priority is moving through the stroke pathway. Requesting a speech therapy consult for communication strategies may be useful after the evaluation, but it does not address urgent reperfusion eligibility. Applying sequential compression devices is a DVT-prevention measure that may be appropriate after diagnosis, but it is not the first action during an acute stroke. Family teaching about stroke rehabilitation and expected recovery is important for discharge planning, but it is premature until the diagnosis and plan are established. The first action must preserve the treatment window by confirming last-known-well time and activating the stroke protocol.

Question 11

A 68-year-old client with a history of hypertension, atrial fibrillation (not taking anticoagulants), type 2 diabetes, and smoking arrives to the emergency department 45 minutes after sudden right-sided arm weakness and slurred speech began. Assessment: awake, answers slowly, facial droop on the right, right arm drift, blood glucose 98 mg/dL (normal 70–110), BP 188/96 mmHg, HR 112 irregular, RR 18/min, SpO2 96% on room air. What is the nurse's PRIORITY action for this client?

  1. Administer aspirin 325 mg by mouth after the bedside swallow screen and repeat vital signs.
  2. Lower blood pressure with the prescribed antihypertensive to below 140/90 mmHg and recheck in one hour.
  3. Obtain a detailed history of symptom progression and home medications from a family member before head imaging.
  4. Activate the stroke alert and prepare the client for immediate noncontrast head computed tomography. (correct answer)
Explanation: The 45-minute onset places the client in the acute stroke treatment window, so the priority is to activate the stroke pathway and obtain a noncontrast head CT that distinguishes ischemic stroke from hemorrhage. That distinction determines whether thrombolysis is an option. Giving aspirin first is incorrect because it assumes an ischemic stroke; if hemorrhage is present, aspirin will worsen bleeding, and a swallow screen does not rule out hemorrhage. Lowering blood pressure to below 140/90 before imaging is also incorrect: aggressive BP reduction can lower cerebral perfusion and is not the safest action before CT results are available. Taking a detailed history before head imaging is useful later but is not the priority; it wastes treatment time. The key decision is to move immediately to imaging and stroke team activation, because delayed diagnosis directly reduces the chances of a good outcome.

Question 12

A 61-year-old client with a history of transient ischemic attacks and carotid artery disease arrives to the emergency department 40 minutes after sudden right facial droop and word-finding difficulty. Assessment: BP 148/82 mmHg, HR 78/min, RR 16/min, SpO2 98% on room air; blood glucose 88 mg/dL (normal 70–110). Which assessment finding requires IMMEDIATE action?

  1. Last known well time cannot be confirmed because the client arrived alone (correct answer)
  2. Blood pressure of 148/82 mmHg because systolic reading is above normal range
  3. Documented history of carotid artery disease and prior transient ischemic attacks
  4. Oxygen saturation of 98% while breathing room air without supplemental oxygen
Explanation: In acute ischemic stroke, thrombolytic therapy is time-limited, and eligibility is anchored to the last known well time. A client who arrives alone with an unconfirmed last known well time creates a gap that must be closed immediately by contacting family, witnesses, or records, because it determines whether the client can receive alteplase within the treatment window. The blood pressure of 148/82 mmHg is mildly elevated but is well below the threshold (typically >185/110 mmHg) that requires urgent blood-pressure management in acute stroke, so it does not demand immediate action. The documented history of carotid artery disease and prior transient ischemic attacks is a significant risk factor but is background information; it does not change the immediate plan. An oxygen saturation of 98% on room air is normal and requires no intervention. Of the four findings, only the unconfirmed last known well time threatens the client's chance of thrombolysis, making it the one that requires immediate action.

Question 13

A 58-year-old client with atrial fibrillation and hypertension arrives to the emergency department 1 hour after sudden onset of right arm weakness and expressive aphasia. Assessment: BP 168/90 mmHg, HR 124 irregular, RR 20/min, SpO2 95% on room air; temperature 98.6°F (37.0°C); blood glucose 110 mg/dL (normal 70–110). What is the nurse's PRIORITY action?

  1. Start an intravenous line and draw blood for coagulation studies while preparing for immediate imaging (correct answer)
  2. Administer an intravenous benzodiazepine for anxiety and apply cardiac monitoring to reduce blood pressure and heart rate
  3. Perform a complete head-to-toe assessment and document neurological findings before activating the stroke team
  4. Give oral fluids to prevent dehydration and administer routine medications prior to computed tomography
Explanation: In acute stroke, the priority is rapid, parallel preparation for imaging and potential thrombolysis. Starting an IV and drawing coagulation studies while preparing for immediate imaging directly supports guideline-based time goals and does not delay care. Administering a benzodiazepine for anxiety is not indicated: it can sedate the patient, obscure neurologic assessment, and unnecessary blood-pressure reduction may worsen cerebral perfusion. Performing a complete head-to-toe assessment before activating the stroke team wastes critical minutes; the nurse should initiate the stroke protocol immediately while doing a focused examination. Giving oral fluids, even with routine medications, is unsafe because a stroke patient must remain NPO to prevent aspiration and to allow emergent thrombolysis or surgery; routine medications are withheld until bleeding risk and imaging results are known. Thus, only the option that combines IV access, laboratory preparation, and rapid imaging readiness meets the urgent needs of acute ischemic stroke.

Question 14

A 72-year-old client is admitted after an acute ischemic stroke and is being evaluated for thrombolytic therapy. History includes hypertension and type 2 diabetes. Assessment: BP 182/96 mmHg, HR 90/min, RR 18/min, SpO2 96% on room air; blood glucose 105 mg/dL (normal 70–110). Which assessment finding requires IMMEDIATE action to prevent delay in time-sensitive treatment?

  1. The exact time of symptom onset is unclear and family members are not yet reached. (correct answer)
  2. The client reports a history of hypertension and has been treated with medication for several years.
  3. A blood glucose of 105 mg/dL is within the normal range and does not suggest hypoglycemia.
  4. SpO2 is 96% on room air and the respiratory rate is 18 per minute.
Explanation: The immediate priority is establishing the last known well time, because thrombolytic eligibility depends on a strict time window. Here the exact time of symptom onset is unclear and family members have not yet been reached, so the team lacks key information needed to decide about thrombolytic therapy and must act immediately to obtain it. A history of hypertension is background and not a time-sensitive barrier; the current blood pressure is below the usual threshold for excluding thrombolytic therapy. A blood glucose of 105 mg/dL is normal, which rules out hypoglycemia as a stroke mimic, and does not need urgent correction. An SpO2 of 96% on room air with a respiratory rate of 18/min is adequate and does not create an immediate need for intervention. Only the unresolved onset time can delay time-sensitive treatment, so it is the priority.

Question 15

A 72-year-old client is receiving post-thrombolytic monitoring after intravenous alteplase for ischemic stroke. History includes hypertension and chronic kidney disease stage 2. Two hours after completion of alteplase, the client develops sudden nausea and vomiting with worsening neurologic status; assessment shows BP 190/102 mmHg, HR 78/min, RR 18/min, oxygen saturation 96% on room air, and new unequal pupils. Which assessment finding requires IMMEDIATE action?

  1. Blood pressure 190/102 mmHg with acute vomiting and neurologic decline (correct answer)
  2. Oxygen saturation 96% on room air
  3. Heart rate 78/min
  4. History of chronic kidney disease stage 2
Explanation: This question tests prioritization and clinical judgment in recognizing post-thrombolytic complications in acute stroke care. The priority framework is identifying life-threatening hemorrhagic transformation after alteplase. The blood pressure of 190/102 mmHg with acute vomiting and neurologic decline (option A) requires immediate action because these findings strongly suggest intracranial hemorrhage, a life-threatening complication of thrombolytic therapy requiring emergent intervention. Options B (normal oxygen saturation) and C (normal heart rate) are stable findings; option D (chronic kidney disease history) is relevant but not an acute concern. The key principle is that hypertension with neurologic deterioration after thrombolytics indicates hemorrhagic conversion requiring immediate blood pressure control and reversal agents. The transferable strategy is to recognize the triad of hypertension, vomiting, and neurologic decline as hemorrhagic transformation requiring immediate intervention to prevent death.

Question 16

A 64-year-old client arrives to the emergency department 4 hours after sudden onset of aphasia and right-sided weakness. History includes hypertension, type 2 diabetes, and smoking. Assessment: awake, follows commands, expressive aphasia, right arm drift; BP 176/90 mmHg, HR 88/min, RR 16/min, oxygen saturation 98% on room air; glucose 132 mg/dL (normal 70–110). Which assessment finding requires IMMEDIATE action?

  1. Last known well time of 4 hours ago (correct answer)
  2. Blood pressure of 176/90 mmHg on arrival
  3. Blood glucose of 132 mg/dL with normal range 70-110
  4. Oxygen saturation of 98% while breathing room air
Explanation: Stroke treatment is time-limited. The last known well time of 4 hours ago is the finding that requires immediate action: the client may still be within the extended 4.5-hour window for IV thrombolysis or eligible for endovascular thrombectomy, but only if the stroke team evaluates him rapidly. The blood pressure of 176/90 mmHg on arrival is elevated but is below the usual threshold that would require active lowering before reperfusion, so it should be monitored rather than treated emergently. The blood glucose of 132 mg/dL is slightly above the normal range but is not hypoglycemia or severe hyperglycemia and does not require immediate correction in this stroke presentation. The oxygen saturation of 98% while breathing room air is adequate and does not call for supplemental oxygen. Thus, the time since the client was last known well, not the routine vital sign or lab value, is what should trigger the acute stroke action plan.

Question 17

A 63-year-old client with a history of transient ischemic attacks, carotid artery stenosis, and hypertension arrives to the emergency department with facial droop and inability to speak. The spouse reports the client was last known well 3 hours ago. Assessment: follows simple commands, expressive aphasia, right-sided weakness, BP 172/88 mmHg, HR 84/min, RR 16/min, oxygen saturation 97% on room air; glucose 98 mg/dL (normal 70–110). Which intervention should the nurse implement FIRST in response to the client's symptoms?

  1. Keep the client NPO and perform a bedside swallow screening to assess aspiration risk
  2. Initiate two large-bore intravenous lines and draw blood for laboratory tests per stroke protocol (correct answer)
  3. Administer aspirin immediately to reduce platelet aggregation and prevent clot extension in cerebral vessels
  4. Place the client in Trendelenburg position to improve cerebral perfusion by enhancing venous return
Explanation: In acute stroke, the immediate priority is to establish vascular access and obtain critical laboratory values to expedite potential thrombolytic decisions. Initiating two large-bore IV lines and drawing blood for tests allows rapid medication administration and provides essential data (coagulation, glucose, platelets) needed before any treatment. Swallow screening is important but not the first step; it follows initial stabilization. Administering aspirin is contraindicated until brain imaging rules out hemorrhage. Trendelenburg positioning increases intracranial pressure and is harmful. Thus, the action that simultaneously supports diagnosis and treatment is the priority.

Question 18

A 58-year-old client with a history of transient ischemic attacks and hypertension arrives to the emergency department 35 minutes after sudden facial droop and difficulty speaking. Assessment: BP 146/84 mmHg, HR 80/min, RR 18/min, SpO2 97% on room air; blood glucose 89 mg/dL (normal 70–110). The client is restless and tries to get out of bed. What is the nurse's PRIORITY action?

  1. Delay imaging until the client is calm to avoid motion artifact
  2. Apply physical restraints to prevent the client from leaving the stretcher
  3. Provide a detailed explanation of computed tomography and ask the client to sign consent
  4. Implement fall precautions, keep the client in bed, and expedite stroke protocol evaluation (correct answer)
Explanation: This question tests prioritization and clinical judgment in acute stroke care. The priority framework balances safety with time-sensitive evaluation. Implementing fall precautions and expediting protocol is the highest priority based on guidelines to prevent injury while advancing care. Applying restraints is inappropriate; detailed explanation delays; delaying imaging risks outcomes. The decision-making principle is patient safety during agitation. Guidelines emphasize non-restraint methods. A transferable strategy is to use least restrictive measures for safety while prioritizing stroke diagnostics in restless patients.

Question 19

A 59-year-old client with hyperlipidemia and prior transient ischemic attack arrives to the emergency department 2 hours after sudden onset of left facial droop and aphasia. Assessment: unable to follow commands, drooling, gurgling voice, BP 164/92 mmHg, HR 88/min, RR 22/min, SpO2 91% on room air, blood glucose 82 mg/dL (normal 70–110). Which intervention should the nurse implement FIRST in response to the client's symptoms?

  1. Administer nothing by mouth and request a speech therapy swallow evaluation
  2. Obtain consent for thrombolytic therapy and start the infusion
  3. Perform a full cranial nerve assessment and document baseline findings
  4. Place the client in a lateral position and suction the airway as needed (correct answer)
Explanation: This question tests prioritization and clinical judgment in acute stroke care. The priority framework focuses on ABCs, particularly airway protection in clients with potential aspiration risk due to dysphagia. Placing the client in a lateral position and suctioning as needed is the highest priority based on clinical guidelines to prevent aspiration pneumonia and maintain oxygenation. Obtaining consent for thrombolytics is premature without imaging; performing a full cranial nerve assessment is lower priority than airway; and keeping NPO with speech evaluation addresses swallowing but not immediate airway compromise. The decision-making principle is to address life-threatening issues like airway obstruction first. Guidelines from the American Stroke Association emphasize early airway management in stroke patients with bulbar symptoms. A transferable strategy is to assess and secure the airway before other interventions in stroke clients showing signs of respiratory distress or secretion issues.

Question 20

A 66-year-old client received intravenous thrombolytic therapy for an ischemic stroke 1 hour ago. History includes hypertension and prior gastrointestinal bleed. The client now reports a sudden severe headache and becomes increasingly confused. Assessment: BP 190/102 mmHg, HR 84/min, RR 16/min, SpO2 97% on room air; pupils unequal compared with baseline. Which assessment finding requires IMMEDIATE action?

  1. SpO2 of 97% on room air
  2. Blood pressure above the client's baseline
  3. History of prior gastrointestinal bleed
  4. New severe headache with acute change in level of consciousness (correct answer)
Explanation: This question tests prioritization and clinical judgment in acute stroke care. The priority framework involves monitoring for complications post-thrombolysis, such as intracranial hemorrhage. The new severe headache with acute change in level of consciousness requires immediate action based on guidelines, indicating possible bleed needing urgent intervention. Elevated blood pressure is common but not immediately actionable alone; history of GI bleed is a risk but not new; SpO2 97% is normal. The decision-making principle is vigilant monitoring for hemorrhage signs post-tPA. American Heart Association guidelines recommend stopping infusion and obtaining emergent CT for deterioration. A transferable strategy is to prioritize reassessment and escalation for any sudden worsening after thrombolytics in stroke care.