# A 67-year-old female was treated with IV alteplase (tPA) 12 hours ago for acute left middle cerebral artery ischemic stroke. Review the chart and determine which assessment finding requires immediate provider notification.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=391799&lang=en  
> language: en  
> subject: Physiological Adaptation  
> category: PA

## Question

A 67-year-old female was treated with IV alteplase (tPA) 12 hours ago for acute left middle cerebral artery ischemic stroke. Review the chart and determine which assessment finding requires immediate provider notification.

History

Vitals

Labs

Orders

Notes

67yo female with HTN, AFib (on apixaban, held), hyperlipidemia. Last known well 14h ago. Symptom onset 13h ago — left MCA ischemic stroke, NIHSS 12 on arrival. IV alteplase given 12h ago within the 4.5h window.

BP 168/92 (1h ago 145/85), HR 88, RR 22, SpO2 95% RA, T 37.0C, GCS 13 (E3 V4 M6, down from 15 one hour ago).

INR 1.2, PT 14, aPTT 32, Plt 250K, Hgb 13.4, Glucose 132, Cr 1.0.

Post-tPA protocol: keep BP <180/105, q15min neuro x2h then q30min x6h then q1h x16h. NPO until swallow eval. No antiplatelets, anticoagulants, or invasive lines x24h. STAT non-contrast head CT if neuro decline.

Mild dysarthria and right arm/leg weakness present since stroke onset (baseline post-stroke, NIHSS 8 after tPA). At hour 12: patient reports worst headache of life, vomited once, eyelids heavy, GCS 13. Cardiology and neurology paged.

1

BP 168/92 mmHg (within post-tPA parameters)

✕

2

New severe headache with vomiting and decreasing level of consciousness

✕

3

Mild slurred speech (unchanged from post-stroke baseline)

✕

4

Right hemiparesis (unchanged from post-stroke baseline)

✕

## Explanation

Post-tPA patients are at highest risk for intracranial hemorrhage (ICH) within the first 24 hours. The triad of new severe headache, vomiting, and decreasing level of consciousness (GCS 15 to 13) is a classic presentation of ICH and requires immediate notification, emergent non-contrast head CT, and reversal protocols (cryoprecipitate, platelets, possible neurosurgery). BP 168/92 is within the post-tPA target (<180/105). Unchanged baseline deficits do not require immediate escalation.

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