Neurological Question #27

Question

The emergency department nurse receives a client with an ischemic stroke, and prepares to administer tissue plasminogen activator (t-PA). What question should the nurse ask first before administering the t-PA?

Answers

  1. Ask the client which arm or leg is affected.
    • Rationale:
  2. Ask the client if speech was slurred.
    • Rationale:
  3. The nurse will ask time of onset of stroke.
    • Rationale:
  4. Ask what home medications the client takes.
    • Rationale:

Overview

Explanation

Timing of onset of stroke is important when receiving t-PA. Studies indicate that clients should receive the thrombolytic medication within 3 hours after the onset of a stroke for best outcomes. While asking about speech changes is important, it is more important to establish time frame of stroke onset. Other questions are not important as the emergent need is to determine if the client is a candidate for t-PA administration.

Learning Outcomes

Test Taking Tip

Video Rationale