# A 67-year-old client arrives at the emergency department 40 minutes after the family saw sudden right-sided weakness, right facial droop, and slurred speech begin; the family clearly documents the last-known-well time. The client cannot raise the right arm against gravity and can wrinkle the forehead on both sides. There was no shaking or tongue biting, and the client has no seizure history. Blood glucose 112 mg/dL. The client takes no anticoagulants. BP 176/94 mm Hg, HR 88/min and irregular, RR 18/min, SpO2 96% on room air. A noncontrast head CT completed 15 minutes after arrival shows no hemorrhage. 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=617354&lang=en > language: en > subject: Establishing Priorities > category: MOC ## Question A 67-year-old client arrives at the emergency department 40 minutes after the family saw sudden right-sided weakness, right facial droop, and slurred speech begin; the family clearly documents the last-known-well time. The client cannot raise the right arm against gravity and can wrinkle the forehead on both sides. There was no shaking or tongue biting, and the client has no seizure history. Blood glucose 112 mg/dL. The client takes no anticoagulants. BP 176/94 mm Hg, HR 88/min and irregular, RR 18/min, SpO2 96% on room air. A noncontrast head CT completed 15 minutes after arrival shows no hemorrhage. 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 Acute ischemic stroke Bell palsy Postictal (Todd) paralysis Hypoglycemic neurologic mimic Actions to take Select 2 Keep the client NPO until a swallow screen Prepare the prescribed thrombolytic Give IV labetalol to bring BP below 140/90 mm Hg Give 50% dextrose IV as a precaution Give oral aspirin 325 mg before the lytic Parameters to monitor Select 2 Serum potassium Forehead wrinkling symmetry NIH Stroke Scale score Hourly urine output Blood pressure ## Explanation Sudden unilateral arm weakness and facial droop with forehead sparing, dysarthria, normal glucose, no seizure, and a CT without hemorrhage within the treatment window is acute ischemic stroke. Preparing the thrombolytic for eligibility review and keeping the client NPO until a swallow screen are priorities. NIHSS and blood pressure show neurologic change and bleeding-risk control. ## In-depth explanation Quick answer Acute ischemic stroke. Take action: prepare the prescribed thrombolytic for eligibility review and keep the client NPO until a swallow screen. Monitor: NIH Stroke Scale score and blood pressure. Why this is correct A central facial droop (forehead spared) plus arm weakness and dysarthria localizes to the brain. The documented last-known-well time places the client well within the thrombolytic window, glucose 112 excludes hypoglycemia, and CT excludes hemorrhage. BP 176/94 is below the 185/110 limit, so it does not need lowering before a lytic. Dysarthria and facial weakness raise aspiration risk, so nothing is given by mouth until the swallow screen. NIHSS and BP are trended frequently during and after thrombolysis. Easy analogy or mental picture Time is brain: the family's clock gives a ticket to the clot-busting line, and the CT confirms there is no bleeding blocking the door. Keep the mouth closed until the swallow test clears the way. Memory hook Clock known + CT clean + BP < 185/110 = LYTIC ready; NPO; watch NIHSS and BP. NCLEX decision rule In a suspected stroke within the window, remove barriers to reperfusion rather than adding steps that delay it, and protect the airway; monitor neurologic score and blood pressure. Why the other choices are wrong Bell palsy is a peripheral lesion that paralyzes the forehead and does not cause arm weakness. Todd paralysis requires a preceding seizure, which did not occur. Hypoglycemia is excluded by glucose 112, so dextrose treats a problem that is not present. Aggressive lowering to below 140/90 is not required before thrombolysis and can reduce brain perfusion; the target is below 185/110. Aspirin is not given before a thrombolytic decision or by mouth before a swallow screen. Forehead symmetry tracks Bell palsy, and potassium and urine output are not specific to stroke response. References 12026 Guideline for the Early Management of Patients With Acute Ischemic StrokeThrombolysis eligibility, pretreatment BP below 185/110, dysphagia screening, and NIHSS monitoring 2MedlinePlus: StrokeStroke warning signs and time-sensitive emergency treatment ## Clinical scenario Scenario Sudden right-sided weakness, facial droop, and dysarthria with a documented last-known-well time 40 minutes before arrival; glucose normal and CT negative for hemorrhage. ## Key concepts - **Last known well** — The last time the client was observed at neurologic baseline; it sets the reperfusion treatment window. - **Forehead sparing** — Preserved forehead movement with lower facial droop, indicating a central (brain) rather than peripheral facial nerve lesion. - **Swallow screen** — A bedside test of safe swallowing required before any oral intake after stroke. ## Related questions - [A nurse in a busy emergency department is triaging five clients who arrive simultaneously.…](https://mymerci.kr/pages/nclex_q.php?qn_id=368320&lang=en) - [At shift change, a charge nurse receives six postoperative reports. 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