Stroke

A nurse is assessing a patient who experienced an acute ischemic stroke 3 days ago. Which assessment finding would be the most critical indicator of potential complications requiring immediate intervention?

1 Sudden severe headache with projectile vomiting and decreased consciousness ✓ 정답
2 Mild confusion with word-finding difficulty during conversation
3 Right-sided weakness and facial droop of moderate severity
4 Blood pressure elevated to 160/90 mmHg with mild headache

해설

Sudden severe headache with projectile vomiting and decreased consciousness indicates increased intracranial pressure or hemorrhagic transformation, requiring immediate intervention. Other findings are expected stroke symptoms or less critical.

같은 주제 다음 문제A nurse is assessing a 65-year-old patient who was admitted 1 hour ago with suspected hemo…이 문제가 수록된 문제집[개념+기출] 엔클렉스(NCLEX), 이거 하나면 됩니다69,000원

Clinical Reasoning and Prioritization

The most critical assessment finding indicating a potential complication that requires immediate intervention is the sudden onset of a severe headache with projectile vomiting and decreased consciousness. In a patient who experienced an acute ischemic stroke 3 days ago, this cluster of symptoms is a classic and alarming presentation for hemorrhagic transformation, a severe early complication. While ischemic stroke results from a blocked vessel, hemorrhagic transformation involves the rupture of the weakened vessel wall into the infarcted brain tissue, leading to an intracerebral hemorrhage. This creates a rapidly expanding mass effect within the rigid skull, causing a sudden and dangerous increase in intracranial pressure (ICP).

The physiological mechanism directly explains the symptoms. The new bleeding and subsequent edema acutely elevate ICP, which triggers the sudden, severe headache often described as a "thunderclap" headache. The rising pressure on the brainstem's vomiting center induces projectile vomiting, a hallmark of central nervous system pathology rather than a gastrointestinal issue. Most critically, the increased ICP compromises cerebral perfusion and can lead to brain herniation, which manifests as a progressive and rapid decline in consciousness. This sequence of events represents a life-threatening neurological emergency that demands immediate recognition and intervention to prevent irreversible brain damage or death. Early identification of patients at high risk for such poor outcomes, including severe neurological deterioration from complications like hemorrhagic transformation, remains a critical challenge in post-stroke care ^[1].

The other options represent expected or less acutely life-threatening findings. Mild confusion with word-finding difficulty (option 2) and moderate right-sided weakness with facial droop (option 3) are common residual neurological deficits from the initial ischemic event. While they require ongoing monitoring and rehabilitation, they do not signal a new, rapidly deteriorating complication. A blood pressure of 160/90 mmHg with a mild headache (option 4) is a frequent finding in the acute post-stroke period. Permissive hypertension is often allowed to maintain cerebral perfusion to the ischemic penumbra, and this clinical picture, while needing careful management, lacks the acute, progressive, and ominous features of increased ICP seen in hemorrhagic transformation. Data from prospective cohort studies confirm that early complications, particularly neurological deterioration, are significant independent predictors of in-hospital mortality after an acute stroke . Therefore, the nurse's ability to rapidly distinguish between expected stroke sequelae and the acute crisis of a new hemorrhage is a fundamental safety priority.

References (research sources)

[1]
Quantitative Cerebrovascular Analysis for Improved Prediction of Post-Stroke Complications.Research articleDeshpande A, Wang J, Altaweel LR, Yi S, Bahiru Z, Leiphart TJ, Tahsili-Fahadan P, Laksari K. (2026) · DOI: 10.1007/s12975-026-01465-2

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A nurse is assessing a patient who experienced an acute ischemic stroke 3 days ago. Which assessment finding would be the most critical indicator of potential complications requiring immediate intervention?

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