# A 66-year-old client weighing 80 kg arrives at the emergency department 40 minutes after family saw the sudden onset of right arm and leg weakness, right facial droop that spares the forehead, and slurred speech. The client has no history of seizures, no seizure activity was witnessed, and the client takes no anticoagulants. Capillary glucose is 112 mg/dL (6.2 mmol/L). Blood pressure is 192/104 mm Hg, heart rate 92/min and irregular, and oxygen saturation 97% on room air. The NIH Stroke Scale score is 9 and has not changed over 20 minutes. A noncontrast head CT completed 15 minutes after arrival shows no hemorrhage. The provider has determined the client is a candidate for IV thrombolysis. 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=617410&lang=en  
> language: en  
> subject: Establishing Priorities  
> category: MOC

## Question

A 66-year-old client weighing 80 kg arrives at the emergency department 40 minutes after family saw the sudden onset of right arm and leg weakness, right facial droop that spares the forehead, and slurred speech. The client has no history of seizures, no seizure activity was witnessed, and the client takes no anticoagulants. Capillary glucose is 112 mg/dL (6.2 mmol/L). Blood pressure is 192/104 mm Hg, heart rate 92/min and irregular, and oxygen saturation 97% on room air. The NIH Stroke Scale score is 9 and has not changed over 20 minutes. A noncontrast head CT completed 15 minutes after arrival shows no hemorrhage. The provider has determined the client is a candidate for IV thrombolysis. 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
Transient ischemic attack
Postictal (Todd) paralysis
Bell palsy
Acute ischemic stroke

Actions to take

Select 2
Give aspirin 325 mg by mouth now
Administer prescribed IV labetalol
Titrate nicardipine to systolic below 140 mm Hg
Administer prescribed IV lorazepam
Prepare the prescribed IV thrombolytic

Parameters to monitor

Select 2
Activated partial thromboplastin time
NIH Stroke Scale score
Serum phenytoin level
Blood pressure every 15 minutes
Capillary glucose every hour

## Explanation

A persistent focal deficit with normal glucose and no hemorrhage on CT is acute ischemic stroke. Blood pressure must be lowered below 185/110 mm Hg before a thrombolytic is given, so the nurse gives prescribed IV labetalol and prepares the thrombolytic. Serial NIH Stroke Scale scores and frequent blood pressure checks detect improvement, hemorrhagic conversion, or loss of pressure control. The aggressive systolic target below 140 mm Hg applies to hemorrhage, not to this client.

## In-depth explanation

Quick answer
Acute ischemic stroke; give prescribed IV labetalol to bring pressure below 185/110 mm Hg and prepare the prescribed IV thrombolytic, then monitor the NIH Stroke Scale score and blood pressure every 15 minutes.

Why this is correct
The deficit is persistent with an NIH Stroke Scale score of 9, the glucose is normal, and CT excludes hemorrhage. The client is a thrombolysis candidate, but a blood pressure of 192/104 mm Hg exceeds the limit for safe thrombolysis, so it must be lowered first. After treatment, frequent neurologic and blood pressure checks detect bleeding and pressure excursions early.

Easy analogy or mental picture
Picture a blocked pipe you want to flush: before opening the valve, lower the pressure so the weakened pipe wall does not burst.

Memory hook
Clot on CT? No bleed → lower BP under 185/110 → then thrombolyse; watch NIHSS and BP.

NCLEX decision rule
When a time-sensitive treatment has a safety threshold, choose the action that makes the client eligible now plus the treatment itself, then monitor the values that signal its main complication.

Why the other choices are wrong
A transient ischemic attack resolves; this deficit is unchanged at 40 minutes with a score of 9, so it is managed as a stroke. Todd paralysis follows a seizure, and none occurred, so lorazepam and a phenytoin level do not apply. Bell palsy involves the forehead and does not cause arm weakness or dysarthria. Aspirin is withheld for 24 hours after thrombolysis and requires a swallow screen. A systolic target below 140 mm Hg is used for intracerebral hemorrhage and would lower cerebral perfusion here. aPTT monitors heparin therapy, and hourly glucose checks are less specific once glucose is normal.

References
1AHA/ASA — 2019 Update to Guidelines for Early Management of Acute Ischemic StrokeBlood pressure must be below 185/110 mm Hg before IV thrombolysis; aspirin is delayed 24 hours after thrombolysis.
2MedlinePlus — StrokeSudden facial droop, arm weakness, and speech difficulty require emergency stroke evaluation.

## Clinical scenario

Scenario
A client with sudden right-sided weakness, facial droop, and dysarthria for 40 minutes has a persistent NIH Stroke Scale score of 9, normal glucose, no hemorrhage on CT, and blood pressure 192/104 mm Hg.

## Key concepts

- **Last known well** — The last time the client was observed at neurologic baseline, which starts the treatment clock.
- **NIH Stroke Scale** — A standardized score of neurologic deficit used to grade stroke severity and track change.
- **Stroke mimic** — A condition such as hypoglycemia, seizure, or Bell palsy that resembles stroke but has a different cause.

## 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. Classify the timing of…](https://mymerci.kr/pages/nclex_q.php?qn_id=393410&lang=en)
- [Review the nurse's escalation timeline for a postoperative client whose condition is deter…](https://mymerci.kr/pages/nclex_q.php?qn_id=393500&lang=en)
- [The nurse receives report on four clients. Which client should the nurse assess first?](https://mymerci.kr/pages/nclex_q.php?qn_id=393675&lang=en)
- [Four hours after open reduction and internal fixation of a fractured tibia, a client repor…](https://mymerci.kr/pages/nclex_q.php?qn_id=394047&lang=en)
- [The nurse receives reports on four clients. Which client should the nurse assess first?](https://mymerci.kr/pages/nclex_q.php?qn_id=394076&lang=en)
- [During a mass casualty incident, which client should be assigned a delayed priority rather…](https://mymerci.kr/pages/nclex_q.php?qn_id=394136&lang=en)
- [During disaster triage, a client is not breathing after the airway is opened and repositio…](https://mymerci.kr/pages/nclex_q.php?qn_id=394166&lang=en)

## Read in another language

- [en](https://mymerci.kr/pages/nclex_q.php?qn_id=617410&lang=en)
- [ko](https://mymerci.kr/pages/nclex_q.php?qn_id=617410&lang=ko)
- [ja](https://mymerci.kr/pages/nclex_q.php?qn_id=617410&lang=ja)
- [zh-TW](https://mymerci.kr/pages/nclex_q.php?qn_id=617410&lang=zh-tw)
- [vi](https://mymerci.kr/pages/nclex_q.php?qn_id=617410&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._