# A 72-year-old presents to the ED with sudden right-sided weakness and aphasia. Family states symptoms began 2 hours ago. BP 168/92. The nurse anticipates which priority next step in the stroke pathway?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=373516&lang=en  
> language: en  
> subject: NCLEX-RN  
> category: ROR

## Question

A 72-year-old presents to the ED with sudden right-sided weakness and aphasia. Family states symptoms began 2 hours ago. BP 168/92. The nurse anticipates which priority next step in the stroke pathway?

## Option

1. Administer aspirin 325 mg PO immediately to prevent further clot formation.
2. Activate the stroke team and obtain a non-contrast head CT within 25 minutes of arrival to rule out hemorrhage before any thrombolytic decision. **✔ Correct answer**
3. Lower the BP aggressively to ≤ 120/80 with IV labetalol before any further evaluation.
4. Schedule an MRI of the brain in the morning to confirm the diagnosis.

**Correct answer: 2**

## Explanation

Acute ischemic stroke pathway: activate stroke team, obtain non-contrast head CT within 25 minutes (must rule out hemorrhage before thrombolytics), and target door-to-needle for IV alteplase ≤ 60 minutes from arrival when within the 4.5-hour window. Aspirin is NOT given before tPA decision (1) — it would delay or contraindicate alteplase. BP is permissive in ischemic stroke up to ~185/110 BEFORE tPA (3 — overaggressive lowering can extend the infarct). MRI is not the initial study (4) — non-contrast CT is faster and adequate to rule out hemorrhage.

## In-depth explanation

Time is brain. Door-to-needle target ≤ 60 minutes for alteplase. Permissive hypertension is allowed up to 185/110 BEFORE tPA — only above that is BP lowered. Aspirin is held until 24 hours AFTER tPA. The classic NCLEX trap is rushing to give aspirin or push BP down — both worsen outcomes.

## Clinical scenario

**72-year-old, sudden onset right-sided weakness and aphasia 2 hours ago**. BP 168/92, HR 88, BG 110. Family confirms last-known-well at 2 hours ago. Suspected **acute ischemic stroke**; tPA window still open.

## Key concepts

- **FAST assessment** — Face droop, Arm weakness, Speech difficulty, Time of last known well — community and EMS stroke screen.
- **tPA / alteplase window** — IV alteplase eligible up to 4.5 hours from last known well (extended criteria 3-4.5 h have additional exclusions).
- **Permissive hypertension (pre-tPA)** — Allow BP up to ~185/110 prior to alteplase; aggressive lowering can extend the ischemic penumbra.

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