A nurse is caring for a patient with hyperthermia following a stroke. Which nursing intervention should be the priority?

Hyperthermia in neurologic patients requires immediate external cooling with continuous monitoring to prevent overcooling. Other options like acetaminophen, increased fluids, or positioning are less urgent.

Understanding the Priority: Hyperthermia in Stroke
In the context of an acute stroke, fever or hyperthermia is not a benign symptom; it is a direct secondary insult to the vulnerable brain. The ischemic penumbra—the area of brain tissue surrounding the core infarct that is functionally impaired but still potentially salvageable—is exquisitely sensitive to temperature elevations. Hyperthermia increases the cerebral metabolic rate of oxygen (CMRO₂), exacerbates neurotransmitter release (specifically glutamate), promotes free radical production, and can lead to the breakdown of the blood-brain barrier. This cascade worsens cerebral edema and increases the risk of neuronal cell death, ultimately leading to a larger infarct size and poorer neurological outcome. Therefore, aggressive and immediate temperature control is a cornerstone of neuroprotective strategy.

Analysis of Interventions
The question asks for the priority intervention, which requires applying the nursing process and physiological prioritization. While all options have some merit in general patient care, only one directly halts the ongoing neurological injury.

The correct answer is Option 1: Apply cooling blankets and monitor core body temperature continuously.
This is the priority because it provides a direct, external, and titratable method to reduce core body temperature. The evidence synthesis on targeted temperature management (TTM) in neurocritical care emphasizes that physical cooling, including surface cooling devices like cooling blankets, is a fundamental intervention for inducing and maintaining normothermia ^[1]. Continuous monitoring is non-negotiable; it allows the nurse to assess the intervention's effectiveness in real-time, prevent overcooling (which can cause shivering and a paradoxical increase in intracranial pressure), and detect temperature fluctuations that require immediate adjustment. This intervention directly addresses the pathophysiology of secondary brain injury.

Option 2: Administer acetaminophen 650 mg orally as prescribed.
While an antipyretic like acetaminophen is a standard pharmacological intervention for fever, it is not the immediate priority in this scenario for two critical reasons. First, the route is problematic in a post-stroke patient. The patient may have dysphagia, an altered level of consciousness, or be at high risk for aspiration, making the oral route potentially unsafe without a formal swallow screening. Second, the effect of an oral antipyretic is delayed and often insufficient as a standalone therapy for the robust hyperthermia seen in neurogenic fever. It should be administered, but only after the nurse has initiated a more direct and rapidly effective cooling method and confirmed the patient's ability to swallow safely.

Option 3: Increase fluid intake to 3000 mL per day as tolerated.
Increasing fluid intake is a supportive measure to prevent dehydration, which can compound hyperthermia, and to promote heat dissipation through diaphoresis. However, it is a slow, indirect method of temperature reduction. Furthermore, the phrase "as tolerated" is a significant safety check in a stroke patient, who may be NPO (nothing by mouth) due to a compromised airway or swallowing. This intervention is supportive, not therapeutic, for the immediate threat of hyperthermia-induced neurological injury.

Option 4: Place the patient in a side-lying position for comfort.
Positioning a stroke patient in a side-lying position is a comfort and airway-protection measure, primarily to maintain a patent airway, facilitate oral secretion drainage, and prevent aspiration. While important for safety and comfort, it has no direct therapeutic effect on lowering core body temperature. It does not address the primary pathophysiological process causing ongoing brain damage.

Clinical Reasoning and Evidence Application
The "best practice evidence for targeted temperature management in neurocritical care patients" highlights the critical need for proactive and precise temperature control to mitigate secondary brain injury ^[1]. The nurse's priority is to select the intervention that most rapidly and effectively breaks the cascade of hyperthermia-induced neuronal injury. Surface cooling with a blanket, coupled with continuous monitoring, allows for the immediate, measurable, and adjustable reduction of core temperature, directly aligning with the principles of TTM ^[1]. This intervention takes precedence over pharmacological support, fluid management, or comfort positioning because it directly targets the most immediate threat to cerebral tissue viability.