A client arrives with sudden aphasia and right-sided weakness. For each proposed early action, identify whether it is appropriate now or unsafe because it delays or compromises acute stroke care.
Matrix
Choose your responses, then check the answer.
Explanation
Acute focal deficits require immediate stroke-pathway activation and a reliable last-known-well time. A bedside glucose check identifies a reversible mimic, and urgent noncontrast brain imaging distinguishes hemorrhage before antithrombotic or reperfusion decisions. Nonessential tests and a complete collateral history should not delay imaging or otherwise eligible treatment. The client remains NPO until swallowing safety is assessed because dysphagia and aspiration are common after stroke. Aspirin is not given before intracranial hemorrhage has been excluded.
Correct Answer Activate the stroke pathway, establish time, check glucose, obtain urgent brain imaging, and maintain NPO status until swallowing safety is assessed.
Why It Fits Treatment eligibility and safety depend on time, exclusion of hemorrhage, rapid recognition of mimics, and prevention of early complications.
Clinical Picture The witness can establish last-known-well, while the client has not yet had imaging or a swallowing screen.
Memory Link Time, glucose, scan, then safe treatment and swallowing.
NCLEX Rule Essential acute stroke evaluation proceeds rapidly; nonessential tests and premature antithrombotic treatment must not delay or compromise care.
Why the Alternatives Fail Waiting for a complete chemistry panel or history, giving aspirin before imaging, or allowing oral intake before screening adds delay or avoidable harm.
Sources
1AHA/ASA 2026 Acute Ischemic Stroke Guideline
2NCSBN 2026 NCLEX-RN Test Plan
Emergency departmentThe symptoms began while the client was speaking with a family member. The client is awake, has facial asymmetry and arm drift, and has not yet undergone brain imaging or a swallowing assessment. The exact last-known-well time can be confirmed by the witness.
Last known well — The latest time the client was known to be without the current neurologic deficit.
Stroke mimic — A nonstroke condition such as hypoglycemia that can produce stroke-like deficits.
Noncontrast brain imaging — Urgent imaging used early to identify intracranial hemorrhage and guide acute treatment decisions.