# A nurse is assessing a 72-year-old patient who was admitted 3 hours ago with suspected acute ischemic stroke. Which assessment finding would be the MOST concerning and require immediate intervention? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541168 > language: ko > subject: Adult Health ## 문제 A nurse is assessing a 72-year-old patient who was admitted 3 hours ago with suspected acute ischemic stroke. Which assessment finding would be the MOST concerning and require immediate intervention? ## 보기 1. Glasgow Coma Scale score decreased from 14 to 12 over the past hour 2. Blood pressure reading of 180/100 mmHg with no previous history of hypertension 3. New onset of expressive aphasia with right-sided facial droop 4. Sudden onset of severe headache with projectile vomiting and decreased level of consciousness **✔ 정답** **정답: 4** ## 해설 Sudden severe headache with projectile vomiting and decreased LOC indicates increased ICP, a neurological emergency requiring immediate intervention like head elevation and notification. Other findings are concerning but less immediately life-threatening. ## 심화 해설 Clinical Judgment This question assesses the ability to identify and prioritize a Critical Cue indicating an immediate life threat in a patient with acute stroke. The key is to distinguish the condition requiring Notify HCP! Option 4's "sudden severe headache, projectile vomiting, decreased level of consciousness" are the classic triad of **acute increased intracranial pressure (Increased ICP)**. When occurring after a stroke, this suggests hemorrhagic transformation, worsening cerebral edema, or expanding intracerebral hemorrhage, an emergency that can lead to **herniation**. The other options are important but do not represent as immediate a life threat as option 4. Memory Tip: To remember the warning signs of acute increased intracranial pressure, think "**H**eadache, **V**omiting, **L**OC change." **H-V-L** are Notify HCP! signs requiring immediate reporting. KR vs US: In Korea, management of early hypertension in stroke may tend to be conservative, but in the US NGN/CJMM, **signs of increased intracranial pressure** are viewed as the top-priority emergency signal, emphasizing immediate neurosurgical/ICU intervention. "Projectile vomiting" is treated as a particularly important neurological sign. ## 임상 시나리오 Clinical Practice Guide If you detect signs of increased intracranial pressure in an acute stroke patient: 1. Immediately notify the HCP and prepare for an emergency CT scan. 2. Elevate the head of the bed to 30 degrees to promote cerebral venous drainage. 3. Keep the patient's neck in a neutral position to avoid obstructing jugular venous drainage. 4. Administer oxygen if needed and prepare for endotracheal intubation. 5. Minimize light and noise stimulation. Caution: A common pitfall in SATA (Select All That Apply) questions is selecting "all abnormal neurological findings in a stroke patient." The priority is on rapidly progressing or life-threatening changes. Hypertension (option 2) or focal neurological deficits (option 3) require management but are not as emergent as signs of increased intracranial pressure. ## 핵심 개념 - **Increased Intracranial Pressure** — A state in which intracranial pressure is abnormally elevated. It occurs due to an increase in the volume of one or more of the following: brain tissue, blood, or cerebrospinal fluid, and is a medical emergency that can lead to brain herniation and death. - **Hemorrhagic Transformation** — A complication where bleeding occurs within the area of an ischemic stroke (blocked blood vessel). It can cause a rapid increase in intracranial pressure. - **Cushing's Triad** — A physiological response that occurs when intracranial pressure becomes very high. It is characterized by hypertension (elevated systolic blood pressure), bradycardia, and irregular breathing. It is a late sign. - **Projectile Vomiting** — Sudden, forceful vomiting without nausea. It is an important sign associated with central nervous system disorders, particularly increased intracranial pressure. - **Cerebral Herniation** — Brain tissue is compressed and displaced beyond its natural compartments within the skull. 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