A client arrives with sudden right-sided weakness and aphasia. The family states the client was last known well 2 hours ago. Which action should the nurse take first?
1Administer aspirin immediately, before the brain imaging results are back.
2Activate the stroke protocol and prepare for urgent brain imaging.✓ Correct answer
3Position the client in a quiet, darkened room and reassess in 1 hour.
4Assess the client's swallowing ability before providing anything by mouth.
Explanation
Sudden focal neurologic deficits within a treatment window require rapid stroke protocol activation and urgent imaging to identify eligibility and rule out hemorrhage. Oral intake should wait until swallowing is assessed. Delaying care or giving aspirin before imaging can be unsafe.
Clinical Judgment Use the client cues, timing, labs, and safety risks to select the response that best fits Acute stroke window.
Memory Tip Match the strongest cue cluster to the safest nursing judgment.
KR vs US NCLEX items reward cue-based priority thinking rather than isolated recall.
Clinical Practice GuideFor Acute stroke window, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.
CautionDo not choose an action from one isolated cue when the full scenario changes priority or safety.
Last Known Well — The time when the client was last observed without stroke symptoms.
Aphasia — Impaired ability to speak or understand language.
Stroke Protocol — A rapid process for assessment, imaging, and time-sensitive stroke treatment decisions.