A nurse is caring for a client who experienced an acute ischemic stroke 6 hours ago and is receiving tissue plasminogen activator (tPA). Which assessment finding requires the nurse's immediate intervention?
1Blood pressure of 160/90 mmHg
2New onset of severe headache with nausea and vomiting✓ 정답
3Slight facial drooping on the affected side
4Difficulty swallowing thin liquids
해설
New onset of severe headache with nausea and vomiting indicates potential intracranial hemorrhage, a life-threatening complication of tPA requiring immediate intervention. Other findings (e.g., hypertension, facial drooping, dysphagia) are concerning but not immediate emergencies.
Core Nursing ExplanationKey Concept Analysis: This question tests the critical nursing priority when monitoring a patient receiving tissue plasminogen activator (tPA) for an acute ischemic stroke. tPA is a powerful thrombolytic ("clot-busting") drug that dissolves the clot causing the stroke to restore blood flow. However, its major risk is causing intracranial hemorrhage (ICH), which can be fatal. The nurse's primary role is vigilant monitoring for signs of this complication. The key is differentiating between expected post-stroke symptoms and new, worsening signs that indicate a hemorrhagic transformation.
Answer Rationale: Key Point! The correct answer is ② New onset of severe headache with nausea and vomiting. This combination of symptoms is a classic, red-flag sign of increased intracranial pressure (ICP) secondary to bleeding. A sudden, severe "thunderclap" headache, especially with nausea/vomiting, suggests active bleeding into the brain or subarachnoid space. This is a life-threatening emergency requiring immediate cessation of the tPA infusion (if still running), notification of the provider, and preparation for emergency interventions like a CT scan and possible neurosurgical consultation.
Distractor Analysis:
Watch out for confusion! Let's analyze why the other options, while important, are not the immediate priority in this specific tPA context.
① Blood pressure of 160/90 mmHg: Hypertension is common after a stroke and is a parameter tightly controlled during tPA therapy. While elevated, this level often has a specific management protocol (e.g., starting antihypertensives if systolic BP >185 mmHg or diastolic >110 mmHg). It requires monitoring and intervention per protocol, but it is not an immediate, singular sign of catastrophic hemorrhage like a new severe headache.
③ Slight facial drooping on the affected side: This is an expected neurological deficit from the original ischemic stroke. The question states the stroke was 6 hours ago; this finding is part of the patient's baseline post-stroke assessment (like weakness or speech difficulty). It does not indicate a new, acute complication.
④ Difficulty swallowing thin liquids: Dysphagia is a very common and serious consequence of stroke, requiring a swallow evaluation to prevent aspiration pneumonia. It is a high nursing priority for safety and care planning. However, like facial drooping, it is typically a result of the initial brain injury, not a new sign of hemorrhage. Managing dysphagia is crucial but not the most immediate life-threatening concern compared to active intracranial bleeding.
Related Concepts: The nurse must understand the strict inclusion/exclusion criteria for tPA (e.g., time window, blood pressure limits, no recent surgery/trauma), the necessity of frequent neurological assessments using tools like the National Institutes of Health Stroke Scale (NIHSS), and the protocol for managing blood pressure during and after infusion. Any sudden change in neurological status—such as a decreased level of consciousness, new weakness, seizure, or the headache described—must be treated as a potential hemorrhage until proven otherwise.
Concept Summary
Concept
Description
Nursing Implication
Tissue Plasminogen Activator (tPA)
Thrombolytic agent used to dissolve clots in acute ischemic stroke. Must be given within a narrow time window (typically 3-4.5 hours from symptom onset).
Monitor for signs of bleeding (intracranial, GI, GU, gingival). Strict BP control. Frequent neuro checks.
Intracranial Hemorrhage (ICH)
The most serious complication of tPA therapy. Bleeding into the brain tissue or spaces.
EMERGENCY. Stop infusion. Notify provider stat. Prepare for CT scan. Signs: Severe HA, nausea/vomiting, neuro decline, seizure.
Dysphagia Post-Stroke
Impaired swallowing due to neurological damage. Risk for aspiration.
NPO until swallow evaluation (often by SLP). Implement aspiration precautions (upright position, thickened liquids).
Monitor closely. Administer antihypertensives per protocol to keep BP below threshold (e.g., 185/110).
Pre-existing facial drooping
Residual deficit from the original ischemic stroke
Document as baseline. Part of ongoing neuro assessment. Not an acute change.
Difficulty swallowing
Post-stroke dysphagia
Important for safety: Keep NPO, consult SLP, prevent aspiration. A high care priority, but not an immediate tPA complication.
Anatomy, Physiology & Pharmacology Points
Pathophysiology: Ischemic stroke blocks a cerebral artery, causing brain cell death (infarction). tPA works by converting plasminogen to plasmin, which breaks down fibrin in the clot. This can also break down fibrin in normal hemostatic plugs, leading to bleeding.
Pharmacology: tPA has a very short half-life. The major antidote or reversal agent for bleeding complications is cryoprecipitate or fresh frozen plasma (FFP) to replace clotting factors, and possibly aminocaproic acid.
Neurological Assessment: Use a standardized scale like the NIHSS. Key components include level of consciousness, gaze, visual fields, facial palsy, motor strength, sensation, language, speech, and neglect.
Memory Tips
Acronym for tPA Bleeding Signs: "Hemorrhage Headache" – Think of the two H's. A sudden, severe Headache is the Herald of Hemorrhage.
Mnemonic for Stroke Assessment (FAST): Face drooping, Arm weakness, Speech difficulty, Time to call 911. For tPA monitoring, add "H" for Headache.
High-Frequency NCLEX Topics
NCLEX loves to test priority-setting and complication recognition. tPA for stroke is a classic high-yield topic. You must know:
1. The time window for administration.
2. The absolute contraindications (e.g., active internal bleeding, history of intracranial hemorrhage, recent major surgery).
3. The #1 complication (intracranial hemorrhage) and its key signs (change in neuro status, severe headache, nausea/vomiting).
4. The importance of blood pressure management before, during, and after infusion.
Watch Out for Question Variations!
* Instead of asking for the finding requiring intervention, the question could ask: "Which finding should the nurse report to the provider immediately?" (Same answer).
* It could shift to patient selection: "Which client is a candidate for tPA therapy?" Testing knowledge of contraindications.
* It could focus on post-administration care: "The nurse should monitor for which adverse effect?" or "Which vital sign parameter is most critical to maintain?"
* It could be an ethics/communication question: "The client's family asks why there's a risk of bleeding. How should the nurse respond?"
Nursing Clinical Practice GuideClinical Scenario: You are the nurse on a neuro unit. Mr. Johnson, 68, received tPA infusion for a left-sided ischemic stroke 2 hours ago. He was initially alert but with right-sided weakness. During your 15-minute neuro check, he groans when you say his name, complains of a "sudden, terrible headache," and then vomits.Nursing Intervention Strategy:
1Immediate Action (ABCs)Ensure a patent airway. Turn patient to side if vomiting to prevent aspiration. Call for help.
2Stop the InfusionIf the tPA IV is still running, stop it immediately. Do not flush the line.
3Notify the Provider STATUse the emergency call system. Report concisely: "Post-tPA patient, new severe headache and vomiting, decreased LOC."
4Rapid AssessmentPerform a quick, focused neuro exam (pupils, GCS, motor response). Check vital signs.
5Prepare for Diagnostics/InterventionAnticipate an immediate non-contrast head CT scan. Have emergency medications (e.g., mannitol for ICP, antihypertensives) and crash cart accessible. Prepare blood products for possible reversal (cryoprecipitate/FFP per order).
Patient Safety and Precautions:
* Pre-tPA: Ensure accurate time of symptom onset. Verify all contraindications are absent. Obtain informed consent explaining the bleeding risk.
* During tPA: Dedicated IV line. No other medications or blood draws from that line. Strict BP monitoring every 15 minutes for 2 hours, then every 30 minutes for 6 hours.
* Post-tPA: Avoid unnecessary invasive procedures (NG tubes, urinary catheters, IM injections) for 24 hours if possible. Monitor all body systems for bleeding (urine, stool, gums, IV sites).
1Baseline AssessmentNIHSS score, vital signs (BP must be <185/110 mmHg), labs (PT/INR, platelets).
2InfusionAdminister exact dose based on weight (0.9 mg/kg, max 90 mg). 10% as IV bolus over 1 minute, remaining 90% infused over 60 minutes.
3Monitoring Schedule* Vital Signs/Neuro: Every 15 min x 2h, then every 30 min x 6h, then hourly x 16h.
* BP Management: If systolic >180 or diastolic >105, administer ordered antihypertensive (e.g., labetalol, nicardipine drip).
4Bleeding PrecautionsBed rest for 24 hours. Use electric razor, soft toothbrush. Handle patient gently.
A Word from Your Senior Nurse
"Nursing is not just about carrying out physician orders — it's about being the frontline guardian for your patients! With a tPA patient, you are holding a very powerful but double-edged sword. Your vigilant, minute-by-minute assessment is what stands between successful reperfusion and a catastrophic bleed. In clinical practice, that 'gut feeling' when a patient just 'isn't right' is often your nursing assessment picking up on subtle cues. When studying for your boards, don't just memorize 'headache = bleed' — understand the why: the ruptured vessel, the rising intracranial pressure. Connect the pathophysiology to the patient's symptom. That deep understanding will not only earn you a great score on the NCLEX but will make you a truly confident, professional nurse who can act decisively to save a life."
Tissue Plasminogen Activator — A thrombolytic ("clot-busting") medication used to treat acute ischemic stroke by dissolving the obstructing blood clot. Major risk is causing bleeding, especially intracranial hemorrhage.
Intracranial Hemorrhage — Bleeding within the skull, which can be into the brain tissue (intracerebral) or the surrounding spaces (subarachnoid, etc.). It is the most serious complication of tPA therapy.
Dysphagia — Difficulty swallowing. A common consequence of stroke that increases the risk for aspiration pneumonia. Requires a formal swallow evaluation before oral intake.
National Institutes of Health Stroke Scale — A standardized tool used by healthcare professionals to objectively quantify the impairment caused by a stroke. It assesses level of consciousness, vision, facial palsy, motor strength, ataxia, sensation, language, speech, and neglect.
Increased Intracranial Pressure — A rise in the pressure inside the skull. Can be caused by bleeding, tumor, or edema. Signs include headache, vomiting, decreased level of consciousness, and pupillary changes.