Acute Stroke: Priority Actions And Care - NCLEX-RN
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Which positioning action best reduces aspiration risk in an acute stroke patient with dysphagia?
Which positioning action best reduces aspiration risk in an acute stroke patient with dysphagia?
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Keep head of bed elevated (about $30^\circ$) and NPO until cleared. Elevation minimizes reflux and aspiration risk, while NPO status ensures safety until swallowing is assessed.
Keep head of bed elevated (about $30^\circ$) and NPO until cleared. Elevation minimizes reflux and aspiration risk, while NPO status ensures safety until swallowing is assessed.
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What is the typical door-to-needle goal time for IV thrombolysis in acute ischemic stroke?
What is the typical door-to-needle goal time for IV thrombolysis in acute ischemic stroke?
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Within $60$ minutes of ED arrival. Minimizes ischemic duration to optimize neuronal preservation and functional recovery per guidelines.
Within $60$ minutes of ED arrival. Minimizes ischemic duration to optimize neuronal preservation and functional recovery per guidelines.
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What is the single most important history element to establish in suspected acute stroke?
What is the single most important history element to establish in suspected acute stroke?
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Last known well (time symptoms were last normal). Determines the onset time critical for eligibility in time-sensitive treatments like thrombolysis and thrombectomy.
Last known well (time symptoms were last normal). Determines the onset time critical for eligibility in time-sensitive treatments like thrombolysis and thrombectomy.
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Which prehospital action most directly speeds definitive acute stroke treatment?
Which prehospital action most directly speeds definitive acute stroke treatment?
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Activate stroke alert and pre-notify the receiving ED. Mobilizes hospital stroke team and resources for expedited evaluation and intervention upon patient arrival.
Activate stroke alert and pre-notify the receiving ED. Mobilizes hospital stroke team and resources for expedited evaluation and intervention upon patient arrival.
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What is the priority imaging test to differentiate ischemic vs hemorrhagic stroke?
What is the priority imaging test to differentiate ischemic vs hemorrhagic stroke?
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Noncontrast head CT. Rapidly rules out hemorrhage, which is essential before initiating thrombolytic therapy for ischemic stroke.
Noncontrast head CT. Rapidly rules out hemorrhage, which is essential before initiating thrombolytic therapy for ischemic stroke.
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Which bedside glucose finding must be corrected before labeling deficits as stroke?
Which bedside glucose finding must be corrected before labeling deficits as stroke?
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Hypoglycemia (low blood glucose). Can mimic stroke symptoms with focal deficits that resolve upon correction, avoiding misdiagnosis.
Hypoglycemia (low blood glucose). Can mimic stroke symptoms with focal deficits that resolve upon correction, avoiding misdiagnosis.
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What is the first nursing priority when a stroke patient has decreased level of consciousness?
What is the first nursing priority when a stroke patient has decreased level of consciousness?
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Airway protection (maintain airway and oxygenation). Prevents hypoxia and aspiration in patients with compromised protective reflexes due to altered consciousness.
Airway protection (maintain airway and oxygenation). Prevents hypoxia and aspiration in patients with compromised protective reflexes due to altered consciousness.
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What oxygenation target is appropriate in acute stroke to avoid routine hyperoxia?
What oxygenation target is appropriate in acute stroke to avoid routine hyperoxia?
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Supplement oxygen only if hypoxic; maintain $SpO_2\geq94%$. Prevents potential harm from hyperoxia, which may increase oxidative stress and worsen ischemic brain injury.
Supplement oxygen only if hypoxic; maintain $SpO_2\geq94%$. Prevents potential harm from hyperoxia, which may increase oxidative stress and worsen ischemic brain injury.
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Which scale is commonly used for rapid prehospital stroke screening?
Which scale is commonly used for rapid prehospital stroke screening?
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FAST (Face, Arm, Speech, Time). Facilitates quick identification of common stroke signs to ensure prompt transport to appropriate care.
FAST (Face, Arm, Speech, Time). Facilitates quick identification of common stroke signs to ensure prompt transport to appropriate care.
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Which in-hospital tool quantifies stroke severity for trending and communication?
Which in-hospital tool quantifies stroke severity for trending and communication?
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NIH Stroke Scale (NIHSS). Offers a standardized, objective measure of neurologic deficits for monitoring changes and guiding decisions.
NIH Stroke Scale (NIHSS). Offers a standardized, objective measure of neurologic deficits for monitoring changes and guiding decisions.
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What is the time goal for completing initial noncontrast head CT after ED arrival?
What is the time goal for completing initial noncontrast head CT after ED arrival?
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Within $20$ minutes of arrival. Enables rapid stroke type differentiation to meet guidelines for timely thrombolytic eligibility assessment.
Within $20$ minutes of arrival. Enables rapid stroke type differentiation to meet guidelines for timely thrombolytic eligibility assessment.
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What is the maximum time window from last known well for IV alteplase in eligible patients?
What is the maximum time window from last known well for IV alteplase in eligible patients?
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Up to $4.5$ hours (selected patients). Evidence from trials supports benefit in improving outcomes for eligible ischemic stroke patients within this period.
Up to $4.5$ hours (selected patients). Evidence from trials supports benefit in improving outcomes for eligible ischemic stroke patients within this period.
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Which medication is first-line for suspected increased intracranial pressure from cerebral edema?
Which medication is first-line for suspected increased intracranial pressure from cerebral edema?
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Mannitol or hypertonic saline (per protocol/provider order). Osmotic agents reduce cerebral edema by drawing fluid from brain tissue into the bloodstream.
Mannitol or hypertonic saline (per protocol/provider order). Osmotic agents reduce cerebral edema by drawing fluid from brain tissue into the bloodstream.
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What is the priority nursing action before giving anything by mouth to an acute stroke patient?
What is the priority nursing action before giving anything by mouth to an acute stroke patient?
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Perform a swallow screen (dysphagia screening). Detects dysphagia early to prevent aspiration pneumonia from oral intake in at-risk patients.
Perform a swallow screen (dysphagia screening). Detects dysphagia early to prevent aspiration pneumonia from oral intake in at-risk patients.
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Identify the priority action when a stroke patient suddenly becomes more confused and drowsy.
Identify the priority action when a stroke patient suddenly becomes more confused and drowsy.
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Reassess neurologic status and activate urgent provider/rapid response for repeat imaging. Sudden changes may indicate deterioration like edema or hemorrhage, requiring prompt evaluation and imaging.
Reassess neurologic status and activate urgent provider/rapid response for repeat imaging. Sudden changes may indicate deterioration like edema or hemorrhage, requiring prompt evaluation and imaging.
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Which complication is a top early priority to prevent in immobile acute stroke patients?
Which complication is a top early priority to prevent in immobile acute stroke patients?
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Venous thromboembolism (DVT/PE). Immobility promotes venous stasis, increasing risk of thrombosis and potentially fatal pulmonary embolism.
Venous thromboembolism (DVT/PE). Immobility promotes venous stasis, increasing risk of thrombosis and potentially fatal pulmonary embolism.
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Which intervention prevents DVT in acute stroke when pharmacologic prophylaxis is not yet safe?
Which intervention prevents DVT in acute stroke when pharmacologic prophylaxis is not yet safe?
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Intermittent pneumatic compression devices. Mechanical compression enhances venous flow, reducing stasis when anticoagulants are contraindicated.
Intermittent pneumatic compression devices. Mechanical compression enhances venous flow, reducing stasis when anticoagulants are contraindicated.
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What is the correct alteplase dosing for acute ischemic stroke?
What is the correct alteplase dosing for acute ischemic stroke?
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$0.9\ \text{mg/kg}$ (max $90$ mg); $10%$ bolus then $90%$ over $60$ min. Standard dosing based on weight ensures effective thrombolysis while minimizing overdose risks.
$0.9\ \text{mg/kg}$ (max $90$ mg); $10%$ bolus then $90%$ over $60$ min. Standard dosing based on weight ensures effective thrombolysis while minimizing overdose risks.
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Which medication class is avoided for $24$ hours after IV alteplase unless ordered otherwise?
Which medication class is avoided for $24$ hours after IV alteplase unless ordered otherwise?
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Antiplatelets and anticoagulants. These agents increase bleeding risk in the vulnerable period following thrombolytic therapy.
Antiplatelets and anticoagulants. These agents increase bleeding risk in the vulnerable period following thrombolytic therapy.
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What is the required timing of follow-up brain imaging after IV alteplase before antithrombotics?
What is the required timing of follow-up brain imaging after IV alteplase before antithrombotics?
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Repeat CT or MRI at $24$ hours. Confirms absence of hemorrhage to safely initiate antithrombotic therapy without exacerbating bleeding.
Repeat CT or MRI at $24$ hours. Confirms absence of hemorrhage to safely initiate antithrombotic therapy without exacerbating bleeding.
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What is the typical time window for mechanical thrombectomy in selected large-vessel occlusion?
What is the typical time window for mechanical thrombectomy in selected large-vessel occlusion?
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Up to $24$ hours in selected patients. Imaging-based selection extends the window for patients with viable tissue, improving outcomes.
Up to $24$ hours in selected patients. Imaging-based selection extends the window for patients with viable tissue, improving outcomes.
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Which imaging study is used to identify large-vessel occlusion for thrombectomy decisions?
Which imaging study is used to identify large-vessel occlusion for thrombectomy decisions?
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CT angiography (CTA) of head and neck. Detects occlusions in major vessels to guide decisions on endovascular thrombectomy eligibility.
CT angiography (CTA) of head and neck. Detects occlusions in major vessels to guide decisions on endovascular thrombectomy eligibility.
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After IV alteplase, what blood pressure target should be maintained to reduce bleeding risk?
After IV alteplase, what blood pressure target should be maintained to reduce bleeding risk?
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Maintain BP $<180/105$ mm Hg. Strict control post-thrombolysis reduces the likelihood of intracranial bleeding complications.
Maintain BP $<180/105$ mm Hg. Strict control post-thrombolysis reduces the likelihood of intracranial bleeding complications.
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Which blood pressure threshold generally requires treatment before giving IV alteplase?
Which blood pressure threshold generally requires treatment before giving IV alteplase?
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BP must be $<185/110$ mm Hg before alteplase. Elevated pressures heighten the risk of hemorrhagic complications during thrombolytic administration.
BP must be $<185/110$ mm Hg before alteplase. Elevated pressures heighten the risk of hemorrhagic complications during thrombolytic administration.
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What is the immediate nursing action if severe headache and vomiting occur during alteplase?
What is the immediate nursing action if severe headache and vomiting occur during alteplase?
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Stop alteplase infusion and obtain emergent head CT. These symptoms suggest possible intracranial hemorrhage, necessitating immediate cessation and diagnostic imaging.
Stop alteplase infusion and obtain emergent head CT. These symptoms suggest possible intracranial hemorrhage, necessitating immediate cessation and diagnostic imaging.
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