This question tests prioritization and clinical judgment in acute stroke care. The priority framework uses ABCs and addresses reversible causes like hypoglycemia mimicking stroke. Administering intravenous dextrose per protocol and reassessing is the highest priority based on guidelines to correct hypoglycemia before further evaluation. Preparing for CT assumes stroke without ruling out mimics; aspirin is contraindicated until hemorrhage is excluded; obtaining last known well is important but secondary to treating low glucose. The decision-making principle is to treat hypoglycemia immediately as it can resolve symptoms. Guidelines mandate glucose check and correction in all suspected strokes. A transferable strategy is to always screen and correct metabolic abnormalities first in acute neuro presentations.

This question tests prioritization and clinical judgment in acute stroke care. The priority framework emphasizes time-sensitive interventions and verifying orders against evidence-based protocols. The nurse should question administering alteplase before CT, as guidelines require ruling out hemorrhage first to avoid catastrophic complications. Keeping NPO until swallow screen prevents aspiration but is standard; obtaining CT STAT is essential; drawing labs is routine for eligibility. The decision-making principle is safety in thrombolytic administration. American Heart Association guidelines contraindicate tPA without confirmatory imaging. A transferable strategy is to always verify imaging results before initiating high-risk therapies in suspected strokes.

This question tests prioritization and clinical judgment in acute stroke care. The priority framework assesses factors impacting thrombolytic eligibility. The unconfirmed last known well time requires immediate action based on guidelines, as it determines treatment window and needs clarification. Normal BP doesn't require action; history is a risk but not acute; normal SpO2 is fine. The decision-making principle is accurate timing for decisions. Guidelines use last known well for eligibility. A transferable strategy is to investigate and document onset details promptly to guide stroke management.

This question tests prioritization and clinical judgment in acute stroke care. The priority framework emphasizes not delaying imaging despite comorbidities like drug use. Activating alert and preparing for CT is the highest priority based on guidelines to diagnose quickly regardless of BP. Administering sedative is not first-line; delaying for BP normalization risks time; drug screen is secondary. The decision-making principle is time-sensitive diagnosis. Guidelines allow imaging with high BP. A transferable strategy is to proceed with protocol activation even in complex cases like substance use.

This question tests prioritization and clinical judgment in acute stroke care. The priority framework monitors for post-tPA complications like increased intracranial pressure. Notifying the team and preparing for CT is the highest priority based on guidelines for signs of herniation or bleed. Administering anticoagulant risks worsening; reassessing delays; providing fluids assumes dehydration. The decision-making principle is rapid imaging for deterioration. Guidelines recommend emergent evaluation for pupil changes. A transferable strategy is to prioritize neuroimaging and escalation for any acute post-treatment neuro decline.

This question tests prioritization and clinical judgment in acute stroke care. The priority framework integrates ABCs with stroke protocol activation. Applying oxygen and activating protocol is the highest priority based on guidelines to optimize perfusion and enable rapid treatment. Administering diuretic assumes heart failure cause; obtaining I&O is secondary; PT consult follows diagnosis. The decision-making principle is addressing hypoxia first. Guidelines recommend SpO2 >=94% in strokes. A transferable strategy is to correct oxygenation while initiating stroke response in hypoxic patients with neuro changes.

This question tests prioritization and clinical judgment in acute stroke care. The priority framework uses time-sensitive interventions for possible hemorrhagic stroke. Activating alert and preparing for CT is the highest priority based on guidelines to rule out bleed in severe headache with neuro deficits. Administering opioid is inappropriate without diagnosis; dimming lights assumes migraine; applying ice delays care. The decision-making principle is differentiating stroke types urgently. Guidelines prioritize imaging for thunderclap headaches. A transferable strategy is to treat severe headache with focal signs as potential hemorrhage and expedite diagnostics.

This question tests prioritization and clinical judgment in acute stroke care. The priority framework involves ABCs and preparing for rapid diagnostics like imaging and labs. Starting an IV and drawing coagulation studies while preparing for imaging is the highest priority based on guidelines to enable timely thrombolysis if eligible. Administering benzodiazepine is not indicated for anxiety alone; complete assessment delays care; giving oral fluids risks aspiration. The decision-making principle is parallel processing to minimize door-to-treatment time. Guidelines recommend IV access and labs within 10 minutes of arrival. A transferable strategy is to multitask essential preparations like access and labs while expediting neuroimaging in acute stroke.

This question tests prioritization and clinical judgment in acute stroke care. The priority framework monitors for bleeding post-thrombolysis. Applying pressure and notifying the team is the highest priority based on guidelines for managing hemorrhage complications. Administering aspirin worsens bleeding; encouraging brushing irritates sites; ambulating risks falls. The decision-making principle is prompt intervention for coagulopathy signs. Guidelines advise stopping anticoagulants and supportive care. A transferable strategy is to inspect sites frequently and escalate any bleeding post-tPA.

This question tests prioritization and clinical judgment in acute stroke care. The priority framework involves recognizing inpatient stroke symptoms and activating rapid response for time-sensitive interventions. Activating the rapid response/stroke protocol and preparing for emergent imaging is the highest priority based on guidelines to ensure quick diagnosis and treatment. Notifying during rounds delays care; administering antibiotics assumes infection without evidence; and reorienting with urine collection addresses delirium but not acute stroke. The decision-making principle is to treat sudden neuro changes as stroke until proven otherwise. Hospital protocols emphasize immediate activation for last known well under 24 hours. A transferable strategy is to document last known well time and escalate care immediately for any new focal deficits in hospitalized patients.