# A nurse is caring for a client who had an ischemic stroke 2 days ago and is receiving anticoagulant therapy. Which assessment finding requires the nurse's immediate attention and intervention?

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## 문제

A nurse is caring for a client who had an ischemic stroke 2 days ago and is receiving anticoagulant therapy. Which assessment finding requires the nurse's immediate attention and intervention?

## 보기

1. Blood pressure of 160/90 mmHg
2. Difficulty swallowing liquids
3. Mild confusion and disorientation
4. Sudden severe headache with vomiting **✔ 정답**

**정답: 4**

## 해설

Sudden severe headache with vomiting suggests intracranial hemorrhage, a life-threatening emergency in a stroke patient on anticoagulant therapy requiring immediate intervention. Other findings (e.g., hypertension, dysphagia, mild confusion) require monitoring but are not immediate threats.

## 심화 해설

Priority Assessment in Post-Stroke Anticoagulation Therapy

The correct answer is sudden severe headache with vomiting. This combination of symptoms is the most critical finding because it represents a classic clinical presentation of a life-threatening symptomatic intracranial hemorrhagic transformation (HT), which requires immediate intervention.

Understanding the Pathophysiology and Clinical Priority

For a client who had an ischemic stroke and is receiving anticoagulant therapy, the primary safety concern is the risk of bleeding, specifically hemorrhagic transformation. As noted in the literature, severe HT is a major complication that "significantly increases the risk of death and disability" and limits the benefit of treatments aimed at restoring blood flow [1]. The nurse must differentiate between expected post-stroke symptoms and signs of this dangerous complication. A sudden severe headache, often described as a "thunderclap" headache, accompanied by vomiting indicates a rapid increase in intracranial pressure (ICP). This is a neurological emergency signaling active intracranial bleeding, which directly threatens the client's airway, breathing, and circulation, aligning with the highest priority in the nursing assessment framework.

Analyzing the Other Options

To understand why the other findings are of lower immediate priority, consider their underlying mechanisms and the context of the client's condition:

- Blood pressure of 160/90 mmHg: In the acute post-stroke period, permissive hypertension is often allowed to maintain cerebral perfusion pressure to the ischemic penumbra. While this reading is elevated and requires ongoing monitoring and eventual management, it is an expected finding and not an immediate life threat like an active hemorrhage. The goal is to avoid hypotension that could worsen the stroke, making this a secondary concern.

- Difficulty swallowing liquids: This finding indicates dysphagia, a common and serious complication after a stroke due to impaired cranial nerve function. It places the client at high risk for aspiration pneumonia. The nurse must intervene by making the client NPO (nothing by mouth) and consulting a speech-language pathologist. However, the risk is one of developing a complication over time, not an immediate, life-threatening change in neurological status.

- Mild confusion and disorientation: Cognitive changes are a direct result of the ischemic injury to brain tissue. While the nurse must assess for changes in the level of consciousness and ensure client safety, a static or mildly fluctuating state of confusion is an expected manifestation of the primary diagnosis. It does not signal a new, rapidly deteriorating process like an intracranial hemorrhage.

Clinical Application of Early Identification

The research underscores the critical nature of early identification of HT. A comprehensive nursing review highlights that recognizing the clinical signs of symptomatic intracranial hemorrhage is a key factor in post-thrombolysis and post-anticoagulation care [1]. The nurse's immediate intervention for a sudden severe headache and vomiting is to stop the anticoagulant infusion, perform a rapid neurological assessment (including Glasgow Coma Scale and pupil reactivity), and urgently notify the healthcare provider to prepare for an emergency CT scan of the head. This rapid response is essential because the angiographic and hemodynamic changes that predict parenchymal hemorrhage, such as the blush sign or increased blood flow velocities on transcranial Doppler, manifest clinically as these acute neurological deteriorations . The nurse at the bedside is in the pivotal position to detect these clinical manifestations first and trigger the emergency response chain.References (research sources)

- [1]Early identification and integrated nursing management of post-thrombolysis hemorrhagic transformation in acute ischemic stroke: a comprehensive review.Research articleYang L, Hu C, Yang Q, Huang H, Hou X. (2025) · DOI: 10.3389/fneur.2025.1704431

## 임상 시나리오

Post-Stroke Anticoagulation: Recognizing Hemorrhagic TransformationPrioritizing sudden headache with vomiting as a neurological emergency
The highest priority for a client on anticoagulation post-ischemic stroke is monitoring for hemorrhagic transformation. A sudden severe headache with vomiting signals a rapid increase in intracranial pressure (ICP), which is a life-threatening emergency requiring immediate intervention to protect the airway and prevent herniation.

In the acute phase, permissive hypertension (allowing SBP up to 220 mmHg) is often protocolized to maintain cerebral perfusion. A BP of 160/90 mmHg is typically not treated urgently unless thrombolytics were administered.

CautionDo not confuse expected post-stroke symptoms with acute deterioration. While dysphagia and mild confusion require management, a thunderclap headache with vomiting demands immediate cessation of anticoagulation and emergency CT imaging.

## 핵심 개념

- **Hemorrhagic Transformation** — A complication of ischemic stroke where blood leaks into the infarcted brain tissue, often worsened by anticoagulation, leading to increased ICP and neurological decline.
- **Thunderclap Headache** — A sudden, severe headache that reaches maximum intensity within seconds to minutes, a classic sign of intracranial hemorrhage or increased ICP.
- **Permissive Hypertension** — The practice of allowing elevated blood pressure (often up to 220/120 mmHg) in acute ischemic stroke to preserve perfusion to the penumbra via collateral circulation.

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