A nurse is caring for a client receiving alteplase (tPA) therapy for an acute ischemic stroke. Which assessment finding requires the nurse's immediate attention and intervention?

New onset severe headache with nausea/vomiting may indicate intracranial hemorrhage, a life-threatening complication of tPA therapy. Other findings (BP 160/90, pre-existing slurred speech, mild fever) require monitoring but are not immediate emergencies.

Core Nursing Explanation Key Concept Analysis: This question tests the critical nursing priority for a patient receiving Alteplase (tissue plasminogen activator, tPA) for an acute ischemic stroke. tPA is a powerful thrombolytic (fibrinolytic) agent that dissolves blood clots to restore cerebral blood flow. Its most feared and potentially fatal complication is intracranial hemorrhage (ICH). The nurse's primary role is vigilant monitoring for signs of this complication, which requires immediate intervention to prevent death or severe disability.

Answer Rationale: Key Point! The correct answer is ① New onset of severe headache with nausea and vomiting. This symptom cluster is a classic, red-flag presentation for intracranial hemorrhage. The sudden, severe headache (often described as "the worst headache of my life") coupled with nausea/vomiting indicates a rapid increase in intracranial pressure (ICP) due to bleeding into the brain. For a patient on tPA, this is a Key Point! medical emergency requiring immediate cessation of the tPA infusion, notification of the physician, and preparation for emergency interventions like a stat CT scan and possible neurosurgical consultation.

Distractor Analysis:
Watch out for confusion! ② Blood pressure reading of 160/90 mmHg: While hypertension is a risk factor for hemorrhage and blood pressure control is crucial during tPA therapy (often kept below 185/110 mmHg), a single reading of 160/90 is not an *immediate* emergency. It requires monitoring and may need pharmacologic management per protocol, but it does not trump the signs of active bleeding.
③ Slight slurring of speech that was present on admission: This is a baseline neurologic deficit from the original stroke. Monitoring for *worsening* of neurologic status is key, but a stable, pre-existing symptom does not indicate a new, acute complication.
④ Temperature elevation to 100.2°F (37.9°C): A mild fever is common post-stroke and requires investigation and management to prevent secondary brain injury. However, it is not the most immediate life-threatening complication of tPA therapy itself.

Related Concepts: Nursing care for tPA administration involves strict eligibility screening, continuous neurologic assessments using tools like the NIH Stroke Scale (NIHSS), and monitoring for other bleeding sites (e.g., gums, IV sites, hematuria). The principle of "time is brain" applies both to initiating tPA rapidly and to recognizing its complications swiftly. Concept Summary

Concept	Explanation
Alteplase (tPA)	Thrombolytic drug used to dissolve clots in acute ischemic stroke. Must be given within a strict time window (often 3-4.5 hours from symptom onset).
Major Complication	Intracranial Hemorrhage (ICH). This is the priority nursing concern.
Key Assessment Findings for ICH	Sudden severe headache, nausea/vomiting, acute neurologic deterioration (e.g., decreased level of consciousness, new weakness, pupil changes), sudden hypertension.
Nursing Action for Suspected ICH	1. STOP tPA infusion immediately. 2. Notify physician/rapid response team STAT. 3. Prepare for emergency CT scan. 4. Monitor vital signs and neurologic status closely.
Other Monitoring	Systemic bleeding (gums, urine, stool, IV sites), blood pressure control, neurologic checks q15min-1hr initially.

Side-by-Side Comparison!

Assessment Finding	During tPA Therapy: Implication & Priority	In General Stroke Care: Implication
New Severe Headache + N/V	HIGHEST PRIORITY. Suspect intracranial hemorrhage. Immediate intervention required.	Can indicate hemorrhagic transformation, worsening edema, or subarachnoid hemorrhage. Requires urgent evaluation.
BP 160/90 mmHg	Requires intervention per protocol (e.g., labetalol, nicardipine) to keep BP below threshold, but not the *most* immediate emergency if stable.	Hypertension is common. Needs management to reduce risk of further vascular events but allows for permissive hypertension in some cases initially.
Mild Fever (100.2°F)	Requires investigation (source? infection?) and treatment (antipyretics) to reduce metabolic demand on the brain.	Same implication. Fever worsens neurologic outcome.

Anatomy, Physiology & Pharmacology Points

• Pathophysiology: Ischemic stroke causes brain cell death due to blocked blood flow. tPA works by converting plasminogen to plasmin, which breaks down fibrin in the clot.
• Risk: The drug cannot distinguish between a pathologic clot and a hemostatic plug. It can cause bleeding anywhere, but bleeding into the already injured, fragile brain vessels is the most dangerous.
• Blood-Brain Barrier: The injured blood-brain barrier in the stroke area is more susceptible to leakage and hemorrhage when exposed to thrombolytics.

Memory Tips

• Acronym: H.A.N.D.S. OFF for tPA Complications
  Headache (severe, new)
  Altered mental status
  Nausea/Vomiting
  Decreased neuro function
  Sudden hypertension
  OFF -> Turn the tPA infusion OFF immediately!
• Think: "New + Neuro = Notify Now." Any NEW neurological symptom or worsening during tPA infusion is an emergency.

High-Frequency NCLEX Topics The NCLEX heavily tests priority-setting and complication recognition. tPA therapy is a classic scenario where you must choose the finding indicating the most acute, life-threatening complication (hemorrhage) over other abnormal but less immediately dangerous findings (like elevated BP or fever). Always ask yourself: "Which finding suggests the patient is deteriorating RIGHT NOW?" Watch Out for Question Variations!

• Shift from Symptom to Action: "The nurse notes a new severe headache in a patient receiving tPA. What is the nurse's priority action?" (Answer: Stop the infusion and notify the physician.)
• Shift to Contraindications: "Which patient history would make the nurse question the order for tPA?" (Answer: Recent major surgery, active internal bleeding, history of intracranial hemorrhage.)
• Shift to Time Management: "A patient arrives with stroke symptoms 2 hours ago. The nurse anticipates preparing which medication?" (Answer: Alteplase/tPA, emphasizing the narrow time window.)

Nursing Clinical Practice Guide Clinical Scenario: You are the nurse in the Emergency Department for Mr. Johnson, 68, who received a diagnosis of acute ischemic stroke and started on an IV alteplase infusion 30 minutes ago. During your routine 15-minute neurologic check, he grabs his head and moans, "My head is exploding," and then vomits into the emesis basin.

Nursing Intervention Strategy:

1. Immediate Action (Within seconds): Key Point! Stop the tPA infusion immediately at the pump and clamp the IV line. Do not wait for an order.
2. Assessment & Communication: Perform a rapid neurologic assessment (level of consciousness, pupils, motor strength). Activate the emergency call system or call the physician/rapid response team STAT. Report concisely: "Patient on tPA, new severe headache and vomiting, suspect intracranial hemorrhage."
3. Preparation & Supportive Care: Elevate the head of the bed to 30 degrees to reduce ICP. Administer supplemental oxygen as ordered. Have emergency airway equipment and medications (like mannitol for ICP) readily available. Prepare the patient for an immediate non-contrast CT scan of the head.
4. Ongoing Monitoring: Monitor vital signs and neurologic status continuously. Anticipate orders for labs (CBC, coagulation studies) and reversal agents (like cryoprecipitate or tranexamic acid) if available per protocol.

Patient Safety and Precautions:

• Pre-Infusion: Ensure strict eligibility screening (time of onset, BP, lab values, history) is completed and documented by two licensed providers.
• During Infusion: Use a dedicated IV line. Avoid unnecessary punctures (e.g., arterial sticks, IM injections). Perform neurologic checks and vital sign monitoring per protocol (often q15min for 2 hours).
• Post-Infusion: Continue monitoring for delayed bleeding. Minimize patient handling and maintain a quiet environment.

Nursing Procedure & Medication Flow tPA Administration & Monitoring Protocol (Typical Flow):

1. Verify Order & Consent: Confirm correct dose based on weight, and ensure informed consent is obtained.
2. Baseline Assessment: Document a full neurologic exam (NIHSS score), vital signs (BP must be below 185/110 mmHg), and labs (platelets, PT/INR, blood glucose).
3. Two-RN Check: Perform independent double-check of the medication, dose, rate, and pump settings.
4. Administration: Administer IV bolus (10% of dose over 1 min), followed by infusion of the remainder over 60 minutes.
5. Monitoring Schedule:
   • Vital Signs & Neuro Checks: q15min for 2 hours, then q30min for 6 hours, then hourly until 24 hours post-infusion.
   • Watch for: Any change in neurologic status, severe headache, nausea/vomiting, hypertension, or signs of systemic bleeding.

A Word from Your Senior Nurse Caring for a stroke patient on tPA is one of the highest-stakes, time-sensitive responsibilities in nursing. Your vigilance is the patient's safety net. Remember, you are the one at the bedside seeing the subtle—or not so subtle—changes first. That severe headache isn't just a complaint; it's a critical signal from the brain. Trust your assessment, act decisively on protocols, and communicate clearly. This combination of knowledge, skill, and courage is what defines great nursing. When you study for the NCLEX, don't just memorize "headache = hemorrhage." Understand the *why* behind it—the fragile vasculature, the lytic mechanism of the drug—so you can apply that knowledge with confidence in any critical situation.