# A client arrives with sudden right-sided weakness and aphasia. The family states the client was last known well 2 hours ago. Which action should the nurse take first?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397319&lang=en  
> language: en  
> subject: Hemodynamics  
> category: PA

## Question

A client arrives with sudden right-sided weakness and aphasia. The family states the client was last known well 2 hours ago. Which action should the nurse take first?

## Option

1. Offer oral fluids to assess swallowing.
2. Activate the stroke protocol and prepare for urgent brain imaging. **✔ Correct answer**
3. Place the client in a dark room and reassess in 1 hour.
4. Administer aspirin before imaging is completed.

**Correct answer: 2**

## Explanation

Sudden focal neurologic deficits within a treatment window require rapid stroke protocol activation and urgent imaging to identify eligibility and rule out hemorrhage. Oral intake should wait until swallowing is assessed. Delaying care or giving aspirin before imaging can be unsafe.

## In-depth explanation

Clinical Judgment
Use the client cues, timing, labs, and safety risks to select the response that best fits Acute stroke window.

Memory Tip
Match the strongest cue cluster to the safest nursing judgment.

KR vs US
NCLEX items reward cue-based priority thinking rather than isolated recall.

## Clinical scenario

Clinical Practice Guide
For Acute stroke window, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.

Caution
Do not choose an action from one isolated cue when the full scenario changes priority or safety.

## Key concepts

- **Last Known Well** — The time when the client was last observed without stroke symptoms.
- **Aphasia** — Impaired ability to speak or understand language.
- **Stroke Protocol** — A rapid process for assessment, imaging, and time-sensitive stroke treatment decisions.

## Related questions

- [A client with chronic obstructive pulmonary disease is sitting upright, using accessory mu…](https://mymerci.kr/pages/nclex_q.php?qn_id=396589&lang=en)
- [A client with a head injury has a Glasgow Coma Scale score that decreased from 14 to 10. W…](https://mymerci.kr/pages/nclex_q.php?qn_id=397148&lang=en)
- [A client with a head injury has a Glasgow Coma Scale score that decreased from 14 to 10. W…](https://mymerci.kr/pages/nclex_q.php?qn_id=397149&lang=en)
- [A client with acute pancreatitis reports severe epigastric pain radiating to the back and …](https://mymerci.kr/pages/nclex_q.php?qn_id=397261&lang=en)
- [A client with acute pancreatitis reports severe epigastric pain radiating to the back and …](https://mymerci.kr/pages/nclex_q.php?qn_id=397262&lang=en)
- [A client arrives with sudden right-sided weakness and aphasia. The family states the clien…](https://mymerci.kr/pages/nclex_q.php?qn_id=397320&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=397319&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=397319&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=397319&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=397319&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=397319&lang=vi)

---

More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en)

_For study reference only. Always follow current clinical guidelines and your institution’s protocols._