A 72-year-old presents to the ED with sudden right-sided wea… | MyMerci
NCLEX-RNROR
Question
A 72-year-old presents to the ED with sudden right-sided weakness and aphasia. Family states symptoms began 2 hours ago. BP 168/92. The nurse anticipates which priority next step in the stroke pathway?
1Administer aspirin 325 mg PO immediately to prevent further clot formation.
2Activate the stroke team and obtain a non-contrast head CT within 25 minutes of arrival to rule out hemorrhage before any thrombolytic decision.✓ Correct answer
3Lower the BP aggressively to ≤ 120/80 with IV labetalol before any further evaluation.
4Schedule an MRI of the brain in the morning to confirm the diagnosis.
Explanation
Acute ischemic stroke pathway: activate stroke team, obtain non-contrast head CT within 25 minutes (must rule out hemorrhage before thrombolytics), and target door-to-needle for IV alteplase ≤ 60 minutes from arrival when within the 4.5-hour window. Aspirin is NOT given before tPA decision (1) — it would delay or contraindicate alteplase. BP is permissive in ischemic stroke up to ~185/110 BEFORE tPA (3 — overaggressive lowering can extend the infarct). MRI is not the initial study (4) — non-contrast CT is faster and adequate to rule out hemorrhage.
In-depth explanation
Time is brain. Door-to-needle target ≤ 60 minutes for alteplase. Permissive hypertension is allowed up to 185/110 BEFORE tPA — only above that is BP lowered. Aspirin is held until 24 hours AFTER tPA. The classic NCLEX trap is rushing to give aspirin or push BP down — both worsen outcomes.
Clinical scenario
72-year-old, sudden onset right-sided weakness and aphasia 2 hours ago. BP 168/92, HR 88, BG 110. Family confirms last-known-well at 2 hours ago. Suspected acute ischemic stroke; tPA window still open.
Key concepts
FAST assessment — Face droop, Arm weakness, Speech difficulty, Time of last known well — community and EMS stroke screen.
tPA / alteplase window — IV alteplase eligible up to 4.5 hours from last known well (extended criteria 3-4.5 h have additional exclusions).
Permissive hypertension (pre-tPA) — Allow BP up to ~185/110 prior to alteplase; aggressive lowering can extend the ischemic penumbra.