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 reading of 160/90 mmHg
2Sudden severe headache with nausea and vomiting✓ 정답
3Mild facial asymmetry on the affected side
4Coughing when drinking 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.
Clinical Judgment
The core of this question assesses the nurse's ability to recognize a life-threatening complication that can occur after tPA administration and to respond immediately. tPA dissolves clots in ischemic stroke but simultaneously greatly increases the risk of cerebral hemorrhage (intracranial hemorrhage). A newly developed severe headache and nausea/vomiting are classic signs of increased intracranial pressure, strongly suggesting cerebral hemorrhage. This is an absolute indicator that ongoing treatment must be stopped and emergency measures initiated.
Memory Tip: A headache after tPA is a Red Flag! Remember "Red Flag Headache." A headache occurring after tPA administration is a red flag signaling cerebral hemorrhage.
KR vs US: In Korea, blood pressure management goals after tPA administration may be somewhat stricter, but by NGN/US standards, a blood pressure around 160/90 mmHg is often managed gradually within an acceptable range during tPA administration. The most critical aspect is monitoring for signs of neurological deterioration (headache, change in consciousness, etc.).
임상 시나리오
Clinical Practice Guide
The nurse's core role during tPA administration is monitoring for bleeding. Assess neurological status every 15 minutes, and watch for headache, vomiting, changes in level of consciousness, and worsening focal neurological signs. If bleeding is suspected, immediately stop the tPA, report to the physician, and prepare for an emergency CT scan.
Caution
In SATA (Select All That Apply) questions asking "what requires immediate intervention during tPA administration," an acceptable blood pressure elevation such as "blood pressure 160/90" is not included in the correct answer. "Mild facial droop" or "difficulty swallowing" require assessment and planning but are not life-threatening emergencies.
핵심 개념
조직 플라스미노겐 활성제 — A thrombolytic agent that dissolves blood clots. It is used to treat acute ischemic stroke and must be administered within 4.5 hours of symptom onset. The main risk is bleeding, particularly intracranial hemorrhage.
두개내출혈 (Intracranial Hemorrhage) — Bleeding that occurs within the brain tissue or in the surrounding spaces (subarachnoid, subdural, epidural). It is the most serious complication of tPA therapy, presenting with headache, vomiting, altered consciousness, and focal neurological signs.
허혈성 뇌졸중 (Ischemic Stroke) — A stroke caused by a blood clot or embolus blocking a cerebral blood vessel, cutting off blood flow to brain tissue. tPA is used to dissolve this clot and restore blood flow.
신경학적 평가 (Neurological Assessment) — Systematic evaluation of consciousness level, pupillary response, motor function, sensation, and language ability. This should be performed regularly in stroke patients, especially those receiving tPA, to detect changes in condition.
연하곤란 — Difficulty swallowing. Commonly occurs after a stroke, increasing the risk of aspiration (food or saliva entering the airway) and pneumonia. Appropriate dietary adjustments are necessary after a swallowing evaluation.