# Place the nursing actions in order for an adult client who arrives with an acute onset of left-sided weakness and slurred speech, with a family report of symptom onset 35 minutes ago.

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> language: en  
> subject: Potential for Alterations in Body Systems  
> category: ROR

## Question

Place the nursing actions in order for an adult client who arrives with an acute onset of left-sided weakness and slurred speech, with a family report of symptom onset 35 minutes ago.

Obtain an urgent non-contrast CT scan of the head to differentiate ischemic from hemorrhagic stroke.

Perform a rapid neurologic assessment and stabilize airway, breathing, and circulation while checking blood glucose.

Maintain NPO status and monitor for neurologic deterioration and swallowing safety.

Determine reperfusion eligibility based on imaging findings, contraindications, and current coagulation status.

Activate the stroke pathway and confirm the exact time the client was last known well.

## Explanation

First, activate the stroke pathway and obtain the exact last known well time, because eligibility for time-sensitive reperfusion depends on this. Then, perform a rapid neurologic assessment and stabilize ABCs while checking glucose to rule out hypoglycemia. Next, obtain urgent brain imaging to differentiate ischemic from hemorrhagic stroke. After imaging, determine reperfusion eligibility based on findings, contraindications, and coagulation status. Finally, maintain NPO status and monitor for neurologic deterioration and swallowing safety.

## In-depth explanation

Quick answer
The correct order is: activate stroke pathway and confirm last known well; perform rapid neurologic assessment and stabilize ABCs; obtain urgent brain imaging; determine reperfusion eligibility; maintain NPO and monitor.

Why this is correct
Stroke care is time-critical. The first step is to activate the stroke team and establish the exact time of symptom onset, which determines eligibility for thrombolysis. Immediate assessment of airway, breathing, circulation, and neurologic status is essential but should not delay activation. Brain imaging is required to distinguish ischemic from hemorrhagic stroke before reperfusion decisions. Reperfusion eligibility can only be determined after imaging and review of contraindications. Ongoing monitoring and NPO status are important but are lower priority than acute treatment decisions.

Clinical picture
In acute stroke, the goal is to minimize time to treatment. The AHA/ASA guidelines emphasize rapid activation, assessment, imaging, and treatment. Blood glucose must be checked early to rule out hypoglycemia as a mimic, but this is part of the initial assessment. Warfarin use and elevated INR are contraindications to thrombolysis, so coagulation status must be considered before reperfusion.

Memory hook
Remember the stroke chain of survival: Detection, Dispatch, Delivery, Door, Data, Decision, Drug, Disposition. The nursing actions align with Door-to-Data and Data-to-Decision steps.

NCLEX decision rule
Prioritize actions that are time-sensitive and prerequisite to others. Activation and last known well time precede assessment details because they mobilize resources and establish eligibility. Imaging precedes reperfusion decisions. Monitoring and NPO are supportive and follow acute treatment.

Why the alternatives are wrong
If the client had hypoglycemia, glucose correction would be first. If the client had airway compromise, ABC stabilization would precede pathway activation. If imaging showed hemorrhage, reperfusion would be contraindicated and blood pressure management would take priority.

Sources
1NCSBN 2026 NCLEX-RN Test Plan
2AHA/ASA 2026 Acute Ischemic Stroke Guideline: Top Things to Know
3NCSBN 2026 NCLEX-RN Test Plan

## Clinical scenario

Emergency department
The client is awake, restless, and unable to follow commands. Blood glucose is 118 mg/dL (74–106 mg/dL). A stroke team and CT scanner are available. The client has a history of hypertension and takes warfarin for atrial fibrillation. The last INR 2 days ago was 2.1 (therapeutic range 2.0–3.0).

## Key concepts

- **Last known well** — The time the client was last seen or known to be at their baseline neurologic status. It is used to determine eligibility for time-sensitive reperfusion therapies.
- **Reperfusion therapy** — Treatments to restore blood flow to the brain, such as intravenous thrombolysis or mechanical thrombectomy, which are time-limited and require ruling out hemorrhage.
- **NIH Stroke Scale** — A standardized neurologic assessment tool used to quantify stroke severity and guide treatment decisions.

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