A 68-year-old patient is admitted to the emergency department with sudden onset of right-sided weakness, slurred speech, and confusion that began 2 hours ago. The patient's vital signs are: BP 180/110 mmHg, HR 88 bpm, RR 20/min, Temperature 98.6°F (37°C). What is the nurse's highest priority action?

Airway assessment is the highest priority per ABC approach, as stroke patients are at risk for airway compromise due to altered consciousness and impaired reflexes. Other actions like blood pressure management, neurological assessment, and CT scan are secondary until airway and breathing are secured.

Clinical Reasoning & Priority Setting

The patient presents with a classic acute stroke syndrome (sudden focal neurological deficit within a 2-hour window). In any acute neurological emergency, the immediate priority is not to diagnose the stroke type or to aggressively manage blood pressure, but to apply the standard resuscitation principle of Airway, Breathing, Circulation (ABC). The patient’s altered mental status (confusion) and slurred speech (dysarthria) indicate a significant risk of compromised airway patency due to loss of protective reflexes or tongue obstruction. Therefore, ensuring airway patency and assessing breathing adequacy is the highest priority action before proceeding to diagnostic imaging or detailed neurological scoring ^[1].

Pathophysiology & Clinical Rationale

In the hyperacute phase of stroke, cerebral autoregulation is often impaired, and the elevated blood pressure of 180/110 mmHg may represent a compensatory mechanism to maintain cerebral perfusion pressure to the ischemic penumbra. Aggressively lowering blood pressure in the emergency department before a CT scan confirms the absence of hemorrhage can precipitate a critical drop in perfusion, extending the infarct core. Current prehospital and emergency department stroke protocols emphasize that blood pressure reduction is generally deferred unless the patient is receiving thrombolysis or has a specific hypertensive emergency affecting other organ systems ^[1]. Thus, option 1 is contraindicated without a CT result.

While obtaining a CT scan (option 4) is the definitive diagnostic step to differentiate ischemic from hemorrhagic stroke and is highly time-sensitive, it is not the nurse’s first action. A patient cannot be safely transported to radiology if their airway is not secured or if they are hypoxic. The stroke code framework prioritizes a rapid primary survey to stabilize the patient before moving to the scanner, as delays caused by respiratory complications during imaging can be catastrophic ^[1]. The Glasgow Coma Scale (option 2) is a component of the neurological assessment but is secondary to the physiological stabilization of the airway and breathing.