A client arrives 45 minutes after sudden right-sided weakness and aphasia. Blood glucose is 96 mg/dL and blood pressure is 178/96 mm Hg. Complete the statement.
Drop-down Cloze
Choose your responses, then check the answer.
Explanation
Sudden aphasia and unilateral weakness within 45 minutes require immediate stroke-pathway activation, last-known-well confirmation, rapid neurologic assessment, and emergent brain imaging to distinguish hemorrhage from ischemia. The stroke team evaluates eligibility for IV thrombolysis and endovascular thrombectomy without avoidable delay. Keep the client NPO and withhold oral fluids and medications until dysphagia screening reduces aspiration risk; continuous monitoring and repeated neurologic assessment continue during the workup.
Correct Answer Activate the stroke pathway, confirm last-known-well, obtain emergent imaging, and avoid oral fluids or medications until swallowing is screened.
Why It Fits Aphasia and unilateral weakness are sudden focal deficits. Normal glucose removes a common mimic, and arrival 45 minutes after onset makes every avoidable delay clinically important.
Clinical Picture The pathway runs on two tracks at once: brain imaging determines hemorrhage versus ischemia and vessel status, while airway, monitoring, and aspiration precautions protect the client during reperfusion evaluation.
Memory Link Time known, glucose checked, imaging now, nothing by mouth until swallow safety is assessed.
NCLEX Rule Do not wait for family, outpatient consultation, or a walking trial. Rapid imaging and stroke-team evaluation come first; the team then determines IV thrombolysis and thrombectomy eligibility.
Why the Alternatives Fail Outpatient referral and endurance testing delay reperfusion assessment. Oral intake before screening can cause aspiration. Cardiac monitoring, neurologic reassessment, and oxygen for hypoxemia remain appropriate and therefore are not the action to avoid.
Source
12026 AHA/ASA acute ischemic stroke guideline
Clinical Practice GuideSudden focal neurologic deficits 45 minutes after onset require immediate stroke-system activation, last-known-well confirmation, glucose assessment, neurologic scoring, and emergent brain and vascular imaging.
CautionKeep the client NPO until dysphagia screening; do not delay imaging or reperfusion evaluation while waiting for family.
Aphasia — Impaired language expression or comprehension.
Last Known Well — The time the client was last known to be without stroke symptoms.
Swallow Screen — A safety screen to reduce aspiration risk after stroke.