A client with a history of hypertension is brought to the emergency department by family members who report that the client suddenly developed right-sided weakness and difficulty speaking 30 minutes ago. The nurse performs a focused assessment and notes a right facial droop, right arm drift, and slurred speech. The nurse should first __0__ and then __1__.
Drop-down Cloze
Choose your responses, then check the answer.
Explanation
The client presents with sudden focal neurologic deficits consistent with an acute ischemic stroke. The priority is rapid evaluation to determine eligibility for reperfusion therapy. The first action is to activate the stroke team and obtain a stat noncontrast head CT to rule out hemorrhage and confirm ischemic stroke. Aspirin should not be given before imaging because it could worsen a hemorrhagic stroke. An ECG is important but not the immediate priority. After CT confirms no hemorrhage and within the thrombolytic window, the nurse should prepare for possible thrombolytic therapy (e.g., alteplase) if no contraindications. Inserting a urinary catheter and initiating heparin are not initial stroke interventions.
The client presents with sudden focal neurologic deficits consistent with an acute ischemic stroke. The priority is rapid evaluation to determine eligibility for reperfusion therapy. The first action is to activate the stroke team and obtain a stat noncontrast head CT to rule out hemorrhage and confirm ischemic stroke. Aspirin should not be given before imaging because it could worsen a hemorrhagic stroke. An ECG is important but not the immediate priority. After CT confirms no hemorrhage and within the thrombolytic window, the nurse should prepare for possible thrombolytic therapy (e.g., alteplase) if no contraindications. Inserting a urinary catheter and initiating heparin are not initial stroke interventions.
Key cues
Use the client-specific assessment findings and timing in the scenario rather than a memorized diagnosis label.
Clinical reasoning
Connect the relevant cues to the safest nursing interpretation and action for this exact care setting.
Why the alternatives do not fit
The distractors are plausible in another context but are unsupported, mistimed, lower priority, or incomplete for the findings presented.
Priority and safety
Address immediate threats first, stay within nursing scope, and reassess the client after the selected intervention.
Takeaway
For recognizing and responding to acute ischemic stroke, select responses that are both clinically supported and appropriate at this point in care.
Sources
CDC Stroke Signs and Symptoms
A client with a history of hypertension is brought to the emergency department by family members who report that the client suddenly developed right-sided weakness and difficulty speaking 30 minutes ago. The nurse performs a focused assessment and notes a right facial droop, right arm drift, and slurred speech. The nurse should first __0__ and then __1__.
Ischemic stroke — A type of stroke caused by blockage of a cerebral artery, leading to brain tissue ischemia and neurologic deficits.
Thrombolytic therapy — Administration of a medication such as alteplase to dissolve a blood clot and restore cerebral blood flow, typically within 4.5 hours of symptom onset.
Noncontrast head CT — An imaging study used to rapidly differentiate ischemic stroke from hemorrhagic stroke before initiating treatment.