# A 67-year-old presents with acute right hemiplegia and aphasia. Last known well 2.5 hours ago. CT shows no hemorrhage. BP 192/106. Which action is the priority?

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=375054&lang=en  
> language: en  
> subject: NCLEX-RN  
> category: PA

## Question

A 67-year-old presents with acute right hemiplegia and aphasia. Last known well 2.5 hours ago. CT shows no hemorrhage. BP 192/106. Which action is the priority?

## Option

1. Lower BP to under 185/110 with IV labetalol, then administer alteplase **✔ Correct answer**
2. Withhold thrombolytic because hemiparesis is mild
3. Administer aspirin 325 mg PO and reassess in 1 hour
4. Wait until BP is under 140/90 before considering thrombolytic

**Correct answer: 1**

## Explanation

Acute ischemic stroke within 4.5 hours of LKW with no contraindications: BP must be lowered to under 185/110 with IV labetalol or nicardipine BEFORE thrombolytic, then alteplase 0.9 mg/kg IV (10 percent bolus, 90 percent over 60 min). Tenecteplase 0.25 mg/kg single bolus is increasingly used. Aggressive lowering to under 140/90 risks ischemic penumbra worsening. Aspirin alone misses the thrombolytic window. NIHSS 18 is significant — withholding for mild deficit is incorrect.

## In-depth explanation

After tPA: BP under 180/105 for 24h, no antithrombotics for 24h, repeat CT at 24h before adding aspirin. LVO patients still get thrombectomy up to 24h with imaging selection.

## Clinical scenario

NIHSS 18. INR 1.0, glucose 124, no recent surgery, no anticoagulants.

## Key concepts

- **alteplase** — Recombinant tissue plasminogen activator; thrombolytic for ischemic stroke within 4.5h.
- **NIHSS** — National Institutes of Health Stroke Scale; quantifies stroke severity.
- **ischemic penumbra** — Salvageable brain tissue around infarct core; saved by reperfusion.

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