NCLEX Practice Question

In managing a patient suspected of ischemic stroke, rapid assessment and prioritization of nursing actions are essential. This case involves a 72-year-old patient presenting with right-sided weakness, slurred speech, and facial drooping—classic stroke signs. The important consideration here is the patient’s sudden neurological deterioration: increased drowsiness, unilateral pupil dilation, and vomiting, alongside severe hypertension. These symptoms strongly indicate increased intracranial pressure and potential hemorrhagic conversion, which dramatically changes the treatment approach. In stroke care, timely administration of tissue plasminogen activator (tPA) can be life-saving by dissolving clots. However, if hemorrhagic transformation occurs, continuing tPA can worsen bleeding and worsen outcomes. Therefore, immediate cessation of tPA evaluation and urgent provider notification to perform a CT scan are critical steps to prevent catastrophic complications. Although controlling blood pressure is important, abruptly lowering it before confirming the type of stroke can reduce cerebral perfusion and worsen brain injury. Similarly, placing the patient in a high Fowler’s position is helpful for reducing aspiration risk, and administering ondansetron can ease nausea, but neither addresses the life-threatening neurological decline. These supportive measures should follow once the primary threat of intracranial hemorrhage is ruled out or managed. Nurses must be well-versed in identifying signs of neurological decline such as altered consciousness, pupil changes, and vomiting, as they signal increased intracranial pressure. Prompt action not only improves patient safety but also supports optimal clinical decision-making during the narrow therapeutic time windows for stroke interventions. This practice question highlights critical clinical judgment skills essential for NCLEX success and real-world nursing practice.