# Stage 1 — Recognize cues. Highlight the findings that require the nurse's immediate action.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617251&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

Stage 1 — Recognize cues. Highlight the findings that require the nurse's immediate action.

At 0800, a 72-year-old client is brought to the emergency department by the spouse, who reports the client was speaking normally at 0715 during breakfast and then suddenly could not get words out. The client understands simple requests but answers in short, effortful phrases. History includes hypertension, hyperlipidemia, migraine with aura since age 30, and a single seizure after a fall in 2014; the client takes no anticonvulsant or anticoagulant. The spouse saw no shaking, and the client reports no headache or visual change today. The eyes deviate toward the left, there is a right lower facial droop, and the right arm drifts to the bed when held up. The client wears a hearing aid in the right ear and has months of nighttime right-hand tingling, diagnosed last year as carpal tunnel syndrome. Vital signs: BP 178/96 mm Hg (unchanged on repeat at 0805 and similar to home readings), HR 88/min, RR 18/min, temperature 36.8 C, SpO2 96% on room air. Point-of-care glucose 118 mg/dL.

## Explanation

A last-known-well time 45 minutes before arrival, expressive aphasia, left gaze deviation, a right lower facial droop that spares the forehead, and right arm drift form an abrupt disabling left-hemisphere deficit inside the reperfusion window. The migraine and remote seizure histories raise mimic questions but the current episode has no aura, headache, or witnessed seizure, a glucose of 118 mg/dL excludes hypoglycemia, BP 178/96 mm Hg is stable, near the client's home readings, and below the 185/110 mm Hg thrombolysis limit, so it is monitored rather than treated, and the right-sided hearing aid and carpal tunnel tingling are chronic right-sided findings that do not explain the new deficits.

## In-depth explanation

Quick answer
Speaking normally at 0715, short effortful phrases, left gaze deviation, right lower facial droop, and right arm drift.

Why this is correct
These findings establish a sudden focal deficit that localizes to one hemisphere (language plus right face and arm, with eyes looking toward the lesion) and a known onset time. Last known well at 0715 with arrival at 0800 means the client is well within the thrombolysis window, so the nurse must activate the stroke pathway immediately. A lower facial droop that spares the forehead points to a central lesion rather than a peripheral facial nerve palsy.

Easy analogy or mental picture
The clock started at 0715 and the damage map points to one side of the brain: a defined start time plus a one-sided map means the stroke team goes now.

Memory hook
"Time + side = stroke team now"; mimics need a positive finding (aura, seizure, low glucose), not just a history.

NCLEX decision rule
Treat a sudden unilateral deficit with a known last-known-well time as a stroke until proven otherwise; a mimic history alone does not delay activation.

Why the other choices are wrong
Migraine with aura is a genuine mimic, but this episode has no aura or headache, so the history does not explain the deficits. A remote seizure raises the possibility of Todd paralysis, yet no seizure was witnessed and the client has had none in years. The right-sided hearing aid and months of nighttime right-hand tingling are tempting because they are on the same side as the weakness, but both are chronic, have documented explanations, and do not cause aphasia, gaze deviation, or arm drift. BP 178/96 mm Hg looks high, but it is stable on repeat, similar to home readings, and below the 185/110 mm Hg limit for thrombolysis, so permissive hypertension is maintained with monitoring rather than immediate lowering. A glucose of 118 mg/dL has already excluded hypoglycemia and needs no action.

References
1AHA/ASA 2019 Guidelines for the Early Management of Acute Ischemic StrokeLast-known-well timing, stroke mimics, blood pressure threshold before thrombolysis, rapid evaluation
2CDC: Signs and Symptoms of StrokeSudden unilateral face, arm, and speech deficits as stroke warning signs

## Clinical scenario

Case update
Emergency arrival — the client has abrupt language and motor deficits that began during breakfast.

## Key concepts

- **Last known well** — The most recent time the client was observed at neurologic baseline, used to determine eligibility for reperfusion therapy.
- **Stroke mimic** — A condition such as hypoglycemia, migraine with aura, or postictal (Todd) paralysis that produces stroke-like deficits without cerebral ischemia.
- **Central facial palsy** — Weakness of the lower face with forehead sparing, caused by an upper motor neuron lesion such as a stroke.

## Related questions

- [A nurse is caring for an alert adult client with type 1 diabetes who reports tremors, swea…](https://mymerci.kr/pages/nclex_q.php?qn_id=360524&lang=en)
- [A 58-year-old client arrives at the emergency department with crushing substernal chest pa…](https://mymerci.kr/pages/nclex_q.php?qn_id=362976&lang=en)
- [A 72-year-old client is brought to the emergency department by family who report that the …](https://mymerci.kr/pages/nclex_q.php?qn_id=363003&lang=en)
- [A 79-year-old client is admitted from a long-term care facility with diarrhea, decreased o…](https://mymerci.kr/pages/nclex_q.php?qn_id=363089&lang=en)
- [A 68-year-old client is admitted to the emergency department with suspected sepsis from a …](https://mymerci.kr/pages/nclex_q.php?qn_id=363987&lang=en)
- [A nurse is caring for an adult client in the emergency department who is suspected to have…](https://mymerci.kr/pages/nclex_q.php?qn_id=363993&lang=en)
- [A nurse is teaching a 72-year-old client with chronic heart failure (reduced ejection frac…](https://mymerci.kr/pages/nclex_q.php?qn_id=366202&lang=en)
- [A nurse is caring for an adult client admitted with diabetic ketoacidosis. Laboratory resu…](https://mymerci.kr/pages/nclex_q.php?qn_id=366294&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=617251&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=617251&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=617251&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=617251&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=617251&lang=vi)

---

More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en)

_For study reference only. Always follow current clinical guidelines and your institution’s protocols._