# A nurse is caring for a client who experienced an acute ischemic stroke 6 hours ago and is receiving tissue plasminogen activator (tPA). Which assessment finding requires the nurse's immediate attention?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=541173  
> language: ko  
> subject: Adult Health

## 문제

A nurse is caring for a client who experienced an acute ischemic stroke 6 hours ago and is receiving tissue plasminogen activator (tPA). Which assessment finding requires the nurse's immediate attention?

## 보기

1. Blood pressure reading of 160/90 mmHg with mild headache
2. Sudden severe headache accompanied by nausea and vomiting **✔ 정답**
3. Mild facial asymmetry on the previously affected side
4. Coughing and choking when attempting to drink water

**정답: 2**

## 해설

New onset of severe headache with nausea and vomiting indicates potential intracranial hemorrhage, a life-threatening complication of tPA requiring immediate intervention. Other findings (hypertension, facial drooping, dysphagia) are expected or less urgent in this context.

## 심화 해설

Clinical Judgment
The core of this question assesses the nurse's ability to recognize a life-threatening complication that can occur after tPA administration and to respond immediately. tPA dissolves clots in ischemic stroke but simultaneously greatly increases the risk of cerebral hemorrhage (intracranial hemorrhage). A newly developed severe headache and nausea/vomiting are classic signs of increased intracranial pressure, strongly suggesting cerebral hemorrhage. This is an absolute indicator that **ongoing treatment must be stopped and emergency measures initiated**.

Memory Tip: A headache after tPA is a **R**ed **F**lag! Remember "**R**ed **F**lag Headache." A headache occurring after tPA administration is a red flag signaling cerebral hemorrhage.

KR vs US: In Korea, blood pressure management goals after tPA administration may be somewhat stricter, but by NGN/US standards, a blood pressure around 160/90 mmHg is often managed gradually within an acceptable range during tPA administration. The most critical aspect is monitoring for **signs of neurological deterioration (headache, change in consciousness, etc.)**.

## 임상 시나리오

Clinical Practice Guide
The nurse's core role during tPA administration is continuous **neurological assessment (Neuro Check)**. Headache, change in level of consciousness (drop in GCS score), new focal neurological deficits (worsening paralysis), vomiting, and pupillary asymmetry are all signs that require immediate reporting. If signs of bleeding are suspected, stop the tPA infusion immediately, maintain the IV line and notify the physician, and prepare for an emergency CT scan.

Caution: A common pitfall in SATA (Select All That Apply) questions is being asked to choose "all assessments important for a stroke patient." In this question, within the specific context of "during tPA administration," you must select only **one sign of a life-threatening complication** that requires "**immediate attention**." Facial drooping or dysphagia are symptoms/complications of the stroke itself, but they do not represent an *emergency situation that is rapidly worsening* due to tPA.

## 핵심 개념

- **tPA (Tissue Plasminogen Activator)** — Tissue plasminogen activator. A thrombolytic agent that dissolves blood clots, used to treat acute ischemic stroke but carries a risk of bleeding.
- **Intracranial Hemorrhage (두개내출혈)** — Intracranial hemorrhage occurring within the skull, including the brain parenchyma, ventricles, and subarachnoid space. It is the most serious complication of tPA therapy.
- **Dysphagia (연하곤란)** — Difficulty swallowing. Commonly occurs after a stroke, and poses risks of aspiration and nutritional deficiency.
- **Neuro Check (신경학적 사정)** — Comprehensive neurological assessment including level of consciousness (GCS), pupils, motor/sensory function, and vital signs. It is a cornerstone of stroke patient management.
- **Facial Drooping (안면 처짐)** — Asymmetry due to muscle weakness on one side of the face. This is a classic symptom of a central stroke, particularly in the middle cerebral artery territory.

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