# A client with a history of hypertension is brought to the emergency department by family members who report that the client suddenly developed right-sided weakness and difficulty speaking 30 minutes ago. The nurse performs a focused assessment and notes a right facial droop, right arm drift, and slurred speech. The nurse should first __0__ and then __1__. > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=620073&lang=en > language: en > subject: Medical Emergencies > category: PA ## Question A client with a history of hypertension is brought to the emergency department by family members who report that the client suddenly developed right-sided weakness and difficulty speaking 30 minutes ago. The nurse performs a focused assessment and notes a right facial droop, right arm drift, and slurred speech. The nurse should first __0__ and then __1__. The nurse should first ::선택::activate the stroke team and obtain a stat noncontrast head CTadminister aspirin 325 mg orallyobtain a 12-lead ECG and then ::선택::prepare for possible thrombolytic therapy if no contraindicationsinsert an indwelling urinary catheterinitiate a continuous heparin infusion. ## Explanation The client presents with sudden focal neurologic deficits consistent with an acute ischemic stroke. The priority is rapid evaluation to determine eligibility for reperfusion therapy. The first action is to activate the stroke team and obtain a stat noncontrast head CT to rule out hemorrhage and confirm ischemic stroke. Aspirin should not be given before imaging because it could worsen a hemorrhagic stroke. An ECG is important but not the immediate priority. After CT confirms no hemorrhage and within the thrombolytic window, the nurse should prepare for possible thrombolytic therapy (e.g., alteplase) if no contraindications. Inserting a urinary catheter and initiating heparin are not initial stroke interventions. ## In-depth explanation Quick answer The client presents with sudden focal neurologic deficits consistent with an acute ischemic stroke. The priority is rapid evaluation to determine eligibility for reperfusion therapy. The first action is to activate the stroke team and obtain a stat noncontrast head CT to rule out hemorrhage and confirm ischemic stroke. Aspirin should not be given before imaging because it could worsen a hemorrhagic stroke. An ECG is important but not the immediate priority. After CT confirms no hemorrhage and within the thrombolytic window, the nurse should prepare for possible thrombolytic therapy (e.g., alteplase) if no contraindications. Inserting a urinary catheter and initiating heparin are not initial stroke interventions. Key cues Use the client-specific assessment findings and timing in the scenario rather than a memorized diagnosis label. Clinical reasoning Connect the relevant cues to the safest nursing interpretation and action for this exact care setting. Why the alternatives do not fit The distractors are plausible in another context but are unsupported, mistimed, lower priority, or incomplete for the findings presented. Priority and safety Address immediate threats first, stay within nursing scope, and reassess the client after the selected intervention. Takeaway For recognizing and responding to acute ischemic stroke, select responses that are both clinically supported and appropriate at this point in care. **Sources** - CDC Stroke Signs and Symptoms ## Clinical scenario A client with a history of hypertension is brought to the emergency department by family members who report that the client suddenly developed right-sided weakness and difficulty speaking 30 minutes ago. The nurse performs a focused assessment and notes a right facial droop, right arm drift, and slurred speech. The nurse should first __0__ and then __1__. ## Key concepts - **Ischemic stroke** — A type of stroke caused by blockage of a cerebral artery, leading to brain tissue ischemia and neurologic deficits. - **Thrombolytic therapy** — Administration of a medication such as alteplase to dissolve a blood clot and restore cerebral blood flow, typically within 4.5 hours of symptom onset. - **Noncontrast head CT** — An imaging study used to rapidly differentiate ischemic stroke from hemorrhagic stroke before initiating treatment. ## 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. 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