# A nurse is caring for a client receiving alteplase (tPA) therapy for an acute ischemic stroke. Which assessment finding requires the nurse's immediate attention and intervention?

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> subject: Adult Health

## 문제

A nurse is caring for a client receiving alteplase (tPA) therapy for an acute ischemic stroke. Which assessment finding requires the nurse's immediate attention and intervention?

## 보기

1. New onset of severe headache with nausea and vomiting **✔ 정답**
2. Blood pressure reading of 160/90 mmHg
3. Slight slurring of speech that was present on admission
4. Temperature elevation to 100.2°F (37.9°C)

**정답: 1**

## 해설

New onset severe headache with nausea/vomiting may indicate intracranial hemorrhage, a life-threatening complication of tPA therapy. Other findings (BP 160/90, pre-existing slurred speech, mild fever) require monitoring but are not immediate emergencies.

## 심화 해설

Correct Answer: 1. New onset of severe headache with nausea and vomiting

This finding is the highest priority because it represents a classic clinical presentation of an acute intracranial hemorrhage (ICH), which is the most feared complication of alteplase (tPA) therapy. In the context of thrombolytic administration for an acute ischemic stroke, the sudden development of a severe headache accompanied by nausea and vomiting strongly suggests a rapid increase in intracranial pressure (ICP) secondary to bleeding. This requires immediate cessation of the infusion and an emergent non-contrast CT scan of the head.

Analysis of the Correct Answer

Alteplase is a fibrinolytic agent that converts plasminogen to plasmin, leading to the dissolution of the pathological clot causing the stroke. However, this systemic fibrinolytic state also impairs the body's ability to maintain hemostasis at the vascular injury site in the brain and elsewhere. A new, severe headache in a patient receiving tPA is an ominous sign of hemorrhagic transformation. The nausea and vomiting are physiological responses to the sudden rise in ICP, which stimulates the area postrema in the medulla. The nurse must recognize this as a neurological emergency and act immediately to prevent further neurological injury and potential herniation. The provided evidence confirms that intracranial hemorrhage is a major complication of intravenous alteplase, making its rapid identification the nurse's top priority [1].

Why the Other Options Are Not the Priority

Option 2: Blood pressure reading of 160/90 mmHg

While this blood pressure is elevated and requires intervention, it is an expected and managed finding in the acute post-stroke period. Current guidelines for post-tPA administration often permit permissive hypertension up to a threshold of 180/105 mmHg to maintain cerebral perfusion to the ischemic penumbra. A reading of 160/90 mmHg would prompt the nurse to recheck the pressure, ensure the antihypertensive infusion parameters are set correctly, and notify the provider, but it does not signal an immediate, life-threatening crisis like an active intracranial bleed does.

Option 3: Slight slurring of speech that was present on admission

This is a baseline neurological deficit for this client. The nurse's role is to perform serial neurological assessments to detect any change or worsening from this baseline. A chronic or unchanged finding is an expected part of the client's clinical picture and does not require immediate intervention beyond continued monitoring and supportive care.

Option 4: Temperature elevation to 100.2°F (37.9°C)

A low-grade fever in the setting of an acute stroke is a concern because hyperthermia increases cerebral metabolic demand and can worsen ischemic injury. It requires prompt intervention with antipyretics and investigation for an infectious source. However, it does not take precedence over a clinical change that signals a potentially fatal hemorrhagic complication. The airway, breathing, and circulation (ABCs) and acute neurological deterioration always take priority in the nursing assessment hierarchy.References (research sources)

- [1]Optimal Timing of Post-Alteplase Brain Computed Tomography: Routine Twenty-Four-Hour Versus Extended Forty-Eight-Hour for Detecting Asymptomatic Intracranial Hemorrhage.Research articleBotkosa P, Lokeskrawee T, Pongnikorn D, Pruksathorn N, Lawanaskol S, Patumanond J, Yaowalaorng J, Chanlaor S, Bumrungpagdee W, Lakdee C. (2025) · DOI: 10.14740/jocmr6378

## 임상 시나리오

tPA Therapy: Recognizing Hemorrhagic TransformationPriority assessment for the nurse during alteplase infusion
The most critical adverse effect of alteplase (tPA) is intracranial hemorrhage (ICH). A new, severe headache with nausea and vomiting is a classic sign of a sudden rise in intracranial pressure (ICP) from bleeding.

This finding requires immediate intervention: stop the tPA infusion, perform an emergent non-contrast CT scan, and notify the provider. Do not delay to treat the headache or nausea as isolated symptoms.

CautionA blood pressure of 160/90 mmHg is often within the permissive hypertension range (typically

## 핵심 개념

- **Alteplase (tPA)** — A thrombolytic agent that converts plasminogen to plasmin to dissolve fibrin clots, used to restore perfusion in acute ischemic stroke but carries a high risk of intracranial hemorrhage.
- **Intracranial Hemorrhage (ICH)** — A life-threatening complication of thrombolytic therapy where bleeding occurs within the skull, classically presenting with a sudden severe headache, nausea, vomiting, and acute neurological decline.
- **Hemorrhagic Conversion** — The process by which an ischemic stroke evolves into a hemorrhagic stroke, often exacerbated by the administration of anticoagulants or thrombolytics like alteplase.

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