# A 72-year-old client arrives at the emergency department with sudden aphasia and right arm and leg weakness that began 2 hours ago and have not improved. No seizure activity was witnessed. NIH Stroke Scale score is 12. Blood pressure is 168/92 mm Hg and point-of-care glucose is 110 mg/dL. Noncontrast head CT shows no intracranial hemorrhage. The initial screen identifies no recent major surgery, active bleeding, or anticoagulant use, and the provider has prescribed IV thrombolysis. The client is gesturing for a drink of water. 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=617403&lang=en > language: en > subject: Therapeutic Procedures > category: ROR ## Question A 72-year-old client arrives at the emergency department with sudden aphasia and right arm and leg weakness that began 2 hours ago and have not improved. No seizure activity was witnessed. NIH Stroke Scale score is 12. Blood pressure is 168/92 mm Hg and point-of-care glucose is 110 mg/dL. Noncontrast head CT shows no intracranial hemorrhage. The initial screen identifies no recent major surgery, active bleeding, or anticoagulant use, and the provider has prescribed IV thrombolysis. The client is gesturing for a drink of water. 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 Hypoglycemia with focal deficits Acute ischemic stroke Transient ischemic attack Actions to take Select 2 Lower BP below 140/90 before the thrombolytic Give the IV thrombolytic without avoidable delay Hold thrombolysis until an MRI confirms infarction Insert an indwelling urinary catheter for output Keep NPO until a bedside swallow screen is passed Parameters to monitor Select 2 Platelet count Hourly urine output NIH Stroke Scale score Blood pressure Seizure activity on EEG ## Explanation Persistent aphasia and right hemiparesis beginning 2 hours ago, with normal glucose and no hemorrhage on CT, indicate acute ischemic stroke. The nurse gives the prescribed thrombolytic without avoidable delay and keeps the client NPO until a bedside swallow screen is passed, because aphasia and hemiparesis raise aspiration risk. NIHSS changes show neurologic response or bleeding, and blood pressure must stay below 180/105 mm Hg after treatment. ## In-depth explanation Quick answer Condition: acute ischemic stroke. Actions: give the IV thrombolytic without avoidable delay and keep the client NPO until a bedside swallow screen is passed. Monitor: NIH Stroke Scale score and blood pressure. Why this is correct Sudden focal deficits that persist, a known last-well time within the treatment window, normal glucose, and a CT without blood fit ischemic stroke eligible for IV thrombolysis. Every minute of delay loses brain tissue, so the drug is given promptly once eligibility is confirmed; BP 168/92 mm Hg is already below the 185/110 threshold. Aphasia and hemiparesis impair swallowing, so nothing is given by mouth until a swallow screen is passed. After thrombolysis, repeated NIHSS scoring detects improvement or hemorrhagic transformation, and BP is kept below 180/105 mm Hg for 24 hours to reduce bleeding risk. Easy analogy or mental picture The blocked artery is a garden hose with a kink: straighten it fast (thrombolytic), then watch the flowers (neuro score) and do not turn the water pressure too high (BP) while the hose is fragile. Memory hook Time is brain; nothing by mouth until the swallow screen; after the drug, 180 over 105 and NIHSS on repeat. NCLEX decision rule For an eligible acute ischemic stroke, give reperfusion therapy without delay, screen swallowing before any oral intake, and monitor neurologic status and blood pressure closely afterward. Why the other choices are wrong Intracerebral hemorrhage is excluded by a CT without blood. Hypoglycemia can cause focal deficits, but glucose is 110 mg/dL. A transient ischemic attack resolves; these deficits have persisted for 2 hours with an NIHSS of 12. Lowering BP to 140/90 before treatment is unnecessary at 168/92 and can reduce flow to the ischemic penumbra. Waiting for MRI confirmation delays reperfusion when CT has excluded hemorrhage. Indwelling urinary catheters are avoided or delayed around thrombolysis because of bleeding and infection risk, so hourly urine output is not the progress measure. Platelet count is a pretreatment eligibility check rather than a progress marker, and no seizure was witnessed, so EEG is not needed. References 1AHA/ASA — Guidelines for the Early Management of Patients With Acute Ischemic Stroke (2019 update)Blood pressure below 185/110 before and below 180/105 for 24 hours after IV thrombolysis; neuro checks; dysphagia screening before oral intake; avoid unnecessary invasive lines and catheters 2CDC — Stroke Signs and SymptomsSudden weakness and speech trouble as stroke warning signs requiring emergency care ## Clinical scenario Scenario Emergency department: persistent aphasia and right hemiparesis for 2 hours, normal glucose, and a CT without hemorrhage. ## Key concepts - **NIH Stroke Scale** — A standardized 0-to-42 scoring of stroke-related neurologic deficits used to assess severity and change. - **IV thrombolysis** — Intravenous clot-dissolving therapy, such as alteplase or tenecteplase, for eligible acute ischemic stroke. - **Hemorrhagic transformation** — Bleeding into an area of ischemic brain, a key risk after thrombolysis. ## Read in another language - [en](https://mymerci.kr/pages/nclex_q.php?qn_id=617403&lang=en) - [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=617403&lang=ko) - [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=617403&lang=ja) - [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=617403&lang=zh-tw) - [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=617403&lang=vi) --- More free questions: [NCLEX-RN Practice](https://mymerci.kr/pages/nclex_bank.php?lang=en) _For study reference only. 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