# A 68-year-old patient is admitted to the emergency department with sudden onset of right-sided weakness, slurred speech, and confusion that began 2 hours ago. The patient's vital signs are: BP 180/110 mmHg, HR 88 bpm, RR 20/min, Temperature 98.6°F (37°C). What is the nurse's highest priority action?

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## 문제

A 68-year-old patient is admitted to the emergency department with sudden onset of right-sided weakness, slurred speech, and confusion that began 2 hours ago. The patient's vital signs are: BP 180/110 mmHg, HR 88 bpm, RR 20/min, Temperature 98.6°F (37°C). What is the nurse's highest priority action?

## 보기

1. Administer antihypertensive medication to reduce blood pressure immediately
2. Obtain a complete neurological assessment using the Glasgow Coma Scale
3. Ensure airway patency and assess breathing adequacy **✔ 정답**
4. Prepare the patient for immediate CT scan of the head

**정답: 3**

## 해설

Airway assessment is the highest priority per ABC approach, as stroke patients are at risk for airway compromise due to altered consciousness and impaired reflexes. Other actions like blood pressure management, neurological assessment, and CT scan are secondary until airway and breathing are secured.

## 심화 해설

Clinical Reasoning & Priority Setting

The patient presents with a classic acute stroke syndrome (sudden focal neurological deficit within a 2-hour window). In any acute neurological emergency, the immediate priority is not to diagnose the stroke type or to aggressively manage blood pressure, but to apply the standard resuscitation principle of Airway, Breathing, Circulation (ABC). The patient’s altered mental status (confusion) and slurred speech (dysarthria) indicate a significant risk of compromised airway patency due to loss of protective reflexes or tongue obstruction. Therefore, ensuring airway patency and assessing breathing adequacy is the highest priority action before proceeding to diagnostic imaging or detailed neurological scoring [1].

Pathophysiology & Clinical Rationale

In the hyperacute phase of stroke, cerebral autoregulation is often impaired, and the elevated blood pressure of 180/110 mmHg may represent a compensatory mechanism to maintain cerebral perfusion pressure to the ischemic penumbra. Aggressively lowering blood pressure in the emergency department before a CT scan confirms the absence of hemorrhage can precipitate a critical drop in perfusion, extending the infarct core. Current prehospital and emergency department stroke protocols emphasize that blood pressure reduction is generally deferred unless the patient is receiving thrombolysis or has a specific hypertensive emergency affecting other organ systems [1]. Thus, option 1 is contraindicated without a CT result.

While obtaining a CT scan (option 4) is the definitive diagnostic step to differentiate ischemic from hemorrhagic stroke and is highly time-sensitive, it is not the nurse’s first action. A patient cannot be safely transported to radiology if their airway is not secured or if they are hypoxic. The stroke code framework prioritizes a rapid primary survey to stabilize the patient before moving to the scanner, as delays caused by respiratory complications during imaging can be catastrophic [1]. The Glasgow Coma Scale (option 2) is a component of the neurological assessment but is secondary to the physiological stabilization of the airway and breathing.References (research sources)

- [1]Updated Protocol for Stroke Code Management in Prehospital Settings: The Iranian Comprehensive Stroke Code Management Program (ICSCM Phase II).Research articleAlijanpour S, Bahramnezhad F, Mowla A, Shafiee Sabet M, Dehghan Nayeri N. (2025) · DOI: 10.22037/aaemj.v13i1.2633

## 임상 시나리오

Acute Stroke: ABC Priority & Permissive HypertensionStabilize the Airway Before the Scanner
In any acute neurological emergency with altered mental status, the nursing priority is the ABC assessment. Secure airway patency and breathing adequacy first, as dysarthria and confusion signal a high risk of aspiration or obstruction.

For ischemic stroke, elevated BP (e.g., 180/110 mmHg) is often a compensatory mechanism to perfuse the ischemic penumbra. Do not aggressively lower BP pre-thrombolysis or pre-CT unless it exceeds 220/120 mmHg or there is end-organ damage. This is termed permissive hypertension.

CautionNever leave a patient with a compromised airway unattended for a CT scan. The stroke team and imaging suite must be ready, but the bedside nurse ensures stabilization (ABCs) before transport.

## 핵심 개념

- **Cerebral Autoregulation** — The brain's ability to maintain constant blood flow despite changes in systemic blood pressure, often impaired in acute stroke.
- **Ischemic Penumbra** — The area of brain tissue surrounding the infarct core that is functionally impaired but still viable, relying on collateral perfusion.
- **Permissive Hypertension** — The clinical strategy of allowing elevated blood pressure in acute ischemic stroke to maintain perfusion to the penumbra, unless thrombolysis is given or BP exceeds 220/120 mmHg.

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