# A nurse is caring for a client who was admitted with a suspected stroke. Which assessment finding would be the highest priority for the nurse to report immediately to the healthcare provider?

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## 문제

A nurse is caring for a client who was admitted with a suspected stroke. Which assessment finding would be the highest priority for the nurse to report immediately to the healthcare provider?

## 보기

1. Sudden onset of severe headache with nuchal rigidity and photophobia **✔ 정답**
2. Mild confusion with disorientation to time and place
3. Unilateral facial drooping with slurred speech pattern
4. Blood pressure reading of 160/90 mmHg with headache

**정답: 1**

## 해설

Sudden severe headache with nuchal rigidity and photophobia indicates subarachnoid hemorrhage or increased ICP, a life-threatening emergency requiring immediate intervention. Other findings (facial droop, mild confusion, elevated BP) are important but less urgent.

## 심화 해설

Clinical Priority Analysis

The correct answer is Option 1. When prioritizing care for a client with a suspected stroke, the nurse must differentiate between findings suggestive of an ischemic stroke and those indicative of a hemorrhagic stroke, specifically a subarachnoid hemorrhage (SAH). The sudden onset of a severe headache with nuchal rigidity and photophobia represents the classic triad of meningeal irritation caused by blood in the subarachnoid space, a condition requiring immediate, life-saving intervention [3].

Pathophysiology and Clinical Significance

A subarachnoid hemorrhage occurs when blood extravasates into the space between the arachnoid mater and pia mater, most commonly from a ruptured cerebral aneurysm [3]. The sudden introduction of blood into this space causes a rapid increase in intracranial pressure (ICP), which accounts for the hallmark "thunderclap headache" often described by patients as the worst headache of their life [4]. The presence of blood acts as a chemical irritant to the meninges, resulting in nuchal rigidity (stiff neck) and photophobia (sensitivity to light). This clinical picture is a neurosurgical emergency because of the high risk of rebleeding, which carries a mortality rate of approximately 70% [3]. Furthermore, the patient is at imminent risk for developing cerebral vasospasm, a leading cause of delayed morbidity and mortality, where blood breakdown products trigger a pathological narrowing of cerebral arteries, leading to secondary ischemia [4].

Comparison with Other Options

While the other findings are clinically significant and require prompt attention, they do not represent the same level of immediate threat to life. Option 2, mild confusion and disorientation, is a common manifestation of many neurological conditions, including ischemic stroke, but does not in itself signal an acute, rapidly deteriorating process like a rebleeding aneurysm. Option 3, unilateral facial drooping and slurred speech, are classic focal neurological deficits consistent with an acute ischemic stroke [1]. Guidelines for acute ischemic stroke management emphasize rapid assessment and intervention, such as fibrinolytic therapy, within a narrow time window [1, 2]. However, the assessment of a severe headache with meningeal signs takes priority because it may contraindicate thrombolytic therapy and necessitates an immediate non-contrast CT scan to rule out hemorrhage before any treatment for presumed ischemia can proceed [1]. Option 4, a blood pressure of 160/90 mmHg with a headache, is a common finding in acute stroke and requires management, but permissive hypertension is often allowed in ischemic stroke to maintain cerebral perfusion [1]. This blood pressure reading, in the absence of signs of meningeal irritation, does not carry the same emergent priority as a sentinel bleed.

Immediate Nursing Actions

The nurse's highest priority is to recognize this symptom cluster as a potential aneurysmal SAH and report it immediately to the healthcare provider to facilitate emergency neuroimaging and neurosurgical consultation [3]. A sudden severe headache in a patient with a suspected stroke must be treated as a hemorrhagic event until proven otherwise, as the initial misdiagnosis of a sentinel bleed can have catastrophic consequences [4].References (research sources)

- [1]Guidelines for the Early Management of Patients With Acute Ischemic StrokeGuidelineEdward C. Jauch, Jeffrey L. Saver, Harold P. Adams, Askiel Bruno, John J. Connors, Bart M. Demaerschalk (2013) · DOI: 10.1161/str.0b013e318284056a

- [3]Guidelines for the Management of Aneurysmal Subarachnoid HemorrhageGuidelineE. Sander Connolly, Alejandro A. Rabinstein, J. Ricardo Carhuapoma, Colin P. Derdeyn, Jacques E. Dion, Randall T. Higashida (2012) · DOI: 10.1161/str.0b013e3182587839

- [4]Vasospasm After Aneurysmal Subarachnoid HemorrhageResearch articleKatie Oyama, Laura M. Criddle (2004) · DOI: 10.4037/ccn2004.24.5.58

## 임상 시나리오

Recognizing Subarachnoid HemorrhageDifferentiating Hemorrhagic from Ischemic Stroke
The classic triad for a subarachnoid hemorrhage (SAH) is a sudden thunderclap headache, nuchal rigidity, and photophobia. This represents a neurosurgical emergency due to the risk of rebleeding.

A thunderclap headache is often described as the worst headache of life and peaks in intensity within 60 seconds. This is caused by a rapid increase in intracranial pressure (ICP) from blood extravasating into the subarachnoid space.

CautionDo not delay reporting for a CT scan. A non-contrast CT is the initial diagnostic test, but a negative scan does not rule out SAH; a lumbar puncture is required to detect xanthochromia. Monitor for cerebral vasospasm, a leading cause of delayed morbidity occurring 4 to 14 days post-hemorrhage.

## 핵심 개념

- **Subarachnoid Hemorrhage (SAH)** — Bleeding into the subarachnoid space, often from a ruptured aneurysm, presenting with a thunderclap headache and meningeal signs.
- **Nuchal Rigidity** — Stiffness of the neck, a classic sign of meningeal irritation caused by blood or infection in the subarachnoid space.
- **Thunderclap Headache** — A sudden, severe headache that reaches maximum intensity within seconds, the hallmark symptom of a subarachnoid hemorrhage.
- **Meningeal Irritation** — Inflammation or chemical irritation of the meninges, producing a triad of headache, nuchal rigidity, and photophobia.
- **Cerebral Vasospasm** — A delayed complication of SAH where blood breakdown products cause cerebral arteries to narrow, leading to secondary ischemic injury.

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