# Stage 3 — Prioritize hypotheses. The 72-year-old client was speaking normally at 0715 and suddenly could not get words out. History includes hypertension, hyperlipidemia, migraine with aura since age 30, and one 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. Findings: effortful short phrases, eyes deviated to the left, right lower facial droop, right arm drift. BP 178/96 mm Hg (similar to home readings), HR 88/min, glucose 118 mg/dL, platelets 224,000/mm3, INR 1.0. Noncontrast CT shows no hemorrhage; CT angiography shows a left M1 occlusion. It is now 0830 and the deficits persist. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=617347&lang=en  
> language: en  
> subject: Establishing Priorities  
> category: MOC

## Question

Stage 3 — Prioritize hypotheses. The 72-year-old client was speaking normally at 0715 and suddenly could not get words out. History includes hypertension, hyperlipidemia, migraine with aura since age 30, and one 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. Findings: effortful short phrases, eyes deviated to the left, right lower facial droop, right arm drift. BP 178/96 mm Hg (similar to home readings), HR 88/min, glucose 118 mg/dL, platelets 224,000/mm3, INR 1.0. Noncontrast CT shows no hemorrhage; CT angiography shows a left M1 occlusion. It is now 0830 and the deficits persist. Complete the diagram by selecting the condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Condition

Select 1
Intracerebral hemorrhage
Acute ischemic stroke
Postictal (Todd) paralysis
Migraine with aura

Actions to take

Select 2
Give the thrombolytic after eligibility check
Give IV lorazepam for a possible seizure
Hold transfer until the lytic response is seen
Prepare for transfer for thrombectomy
Give aspirin 325 mg once swallowing is cleared

Parameters to monitor

Select 2
NIH Stroke Scale score
Serum lipid panel
Blood pressure
Continuous EEG tracing
International normalized ratio

## Explanation

Sudden aphasia, left gaze deviation, and right face and arm weakness with a left M1 occlusion and no hemorrhage on CT is an acute ischemic stroke from large-vessel occlusion, within 75 minutes of last known well. Thrombolysis after eligibility verification and simultaneous thrombectomy transfer are both indicated; waiting for a lytic response delays reperfusion. NIHSS and blood pressure are the key post-reperfusion parameters.

## In-depth explanation

Quick answer
Acute ischemic stroke with large-vessel occlusion. Take action: thrombolytic after the final eligibility check, and prepare for thrombectomy transfer. Monitor: NIH Stroke Scale score and blood pressure.

Why this is correct
The deficits localize to the left hemisphere, began at a witnessed time, and match the M1 occlusion; CT excludes hemorrhage, glucose excludes a metabolic mimic, and INR and platelets remove laboratory exclusions. BP 178/96 is already below the 185/110 limit for thrombolysis. Guidelines support giving an eligible client a thrombolytic and sending for thrombectomy without waiting to see whether the lytic works. After reperfusion the nurse trends NIHSS for improvement or deterioration and keeps blood pressure at or below 180/105 to limit hemorrhagic conversion.

Easy analogy or mental picture
A pipe is blocked: dissolve the clot with the drug and send the plumber with the retrieval tool at the same time; watch the pressure gauge and whether the water flows (the neuro score).

Memory hook
LVO = LYSE and LIFT (lytic plus thrombectomy); watch NIHSS and BP.

NCLEX decision rule
When imaging confirms an ischemic stroke in the treatment window, choose the reperfusion actions that run in parallel, and monitor the neurologic score and the bleeding-risk vital sign.

Why the other choices are wrong
CT rules out hemorrhage. A remote post-fall seizure without witnessed shaking does not explain an occluded artery, so lorazepam and EEG track the Todd paralysis differential. Migraine aura is positive and spreading and the client has no headache today. Delaying transfer for a lytic response loses brain tissue. Aspirin is withheld for 24 hours after thrombolysis, so giving it after the swallow screen is the right drug at the wrong time. INR tracks warfarin and a lipid panel is long-term prevention, not response to reperfusion.

References
12026 Guideline for the Early Management of Patients With Acute Ischemic StrokeThrombolysis eligibility, BP thresholds, thrombectomy for LVO, and post-reperfusion monitoring

## Clinical scenario

Case update
Imaging confirms no hemorrhage and a left M1 occlusion while disabling deficits persist.

## Key concepts

- **Large-vessel occlusion** — Blockage of a major intracranial artery such as the M1 segment of the middle cerebral artery, eligible for thrombectomy.
- **NIH Stroke Scale** — A standardized neurologic score used to measure stroke severity and change after treatment.
- **Post-thrombolysis BP limit** — Blood pressure is kept at or below 180/105 mm Hg after a thrombolytic to reduce bleeding risk.

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