✅ Left-sided facial droop

💎 Left-sided facial droop is an acute neurological deficit and is highly concerning for a stroke.

💎 Facial drooping occurs when blood flow to part of the brain is interrupted, affecting facial muscle control.

💎 Because the client was last known well at 0745 and arrived at 0900, this is a time-sensitive finding.

💎 The nurse should notify the stroke team/provider immediately because early treatment can reduce permanent brain injury.

💎 Facial droop is one of the major warning signs included in stroke recognition tools such as FAST.

✅ Blood pressure

🔷 The blood pressure is 200/102 mm Hg, which is severely elevated and requires immediate follow-up.

🔷 Severe hypertension increases the risk of worsening brain injury, bleeding, and complications during acute stroke treatment.

🔷 Blood pressure must be evaluated quickly because thrombolytic therapy has specific blood pressure safety requirements.

🔷 The nurse should continue frequent vital sign and neurological assessments while preparing for urgent stroke evaluation.

🔷 This finding is especially concerning because the client has a history of hypertension and hyperlipidemia, both major stroke risk factors.

✅ Left visual field deficit

🟢 A left visual field deficit is an acute neurological change that can occur with stroke affecting the visual pathways in the brain.

🟢 Visual field loss increases the client’s risk for injury because they may not see objects, people, or hazards on the affected side.

🟢 This finding helps localize the neurological problem and should be included in the urgent stroke assessment.

🟢 The nurse should institute safety precautions, keep needed items within the client’s visual field, and report the deficit promptly.

🟢 Sudden vision changes are considered a warning sign of acute cerebrovascular disease.

✅ Left arm weakness

🟣 Left arm weakness is a major acute focal neurological deficit and strongly supports suspected stroke.

🟣 Unilateral weakness suggests impaired motor function from interruption of blood flow to the brain.

🟣 This finding requires immediate follow-up because rapid intervention is essential to preserve brain tissue.

🟣 The nurse should assess strength, sensation, speech, swallowing, and level of consciousness while activating stroke protocols.

🟣 Left arm weakness combined with facial droop and visual deficit indicates a possible acute ischemic stroke.

❌ Body temperature

❌ The client’s temperature is 98.5° F (36.9° C), which is within the expected range.

❌ This does not suggest fever, infection, or temperature-related instability requiring immediate follow-up.

❌ Heart rate

❌ The heart rate is 100 beats/min, which is at the upper limit of normal to mildly elevated.

❌ In this scenario, it is less urgent than the acute neurological deficits and severe blood pressure elevation.

❌ Oxygen saturation

❌ The oxygen saturation is 95% on room air, which is within the acceptable range.

❌ This does not indicate acute hypoxia or respiratory compromise at this time.

Intracerebral hemorrhage

💎 The client has acute stroke-like findings: left-sided facial droop, left arm weakness, and left visual field deficit.

💎 The client’s blood pressure is 200/102 mm Hg, which is severely elevated and increases the risk of bleeding into brain tissue.

💎 Even though the initial CT shows no hemorrhage, the client remains at risk because severe hypertension can worsen vascular injury.

💎 If thrombolytic therapy is being considered for suspected ischemic stroke, uncontrolled blood pressure also increases the risk for intracerebral bleeding.

💎 The nurse should continue frequent neurological checks and report any worsening headache, vomiting, decreased level of consciousness, or neurological decline.

Cerebral edema

🔷 Acute stroke can lead to cerebral edema because injured brain tissue becomes inflamed and fluid shifts into the affected area.

🔷 Swelling can increase intracranial pressure, which can reduce cerebral perfusion and worsen neurological damage.

🔷 The client already has focal neurological deficits, so any worsening symptoms could indicate progression of brain injury or swelling.

🔷 The nurse should monitor for decreased level of consciousness, new confusion, worsening weakness, pupillary changes, vomiting, or severe headache.

🔷 Cerebral edema is an immediate concern after acute brain injury because it can progress quickly and become life-threatening.

❌ Deep venous thrombosis

❌ A stroke client can develop DVT later because weakness and immobility reduce venous return.

❌ This is not the most immediate risk compared with brain bleeding or swelling in the acute stroke window.

❌ Tachypnea

❌ Tachypnea means an increased respiratory rate, usually greater than 20/min in adults.

❌ The client’s respiratory rate is 20/min, and oxygen saturation is 95% on room air, so respiratory compromise is not the immediate concern.

❌ Hyperlipidemia

❌ Hyperlipidemia is a chronic risk factor for stroke because it contributes to atherosclerosis.

❌ It is already part of the client’s health history, not an immediate complication developing from the current acute event.

✅ The client’s significant stroke deficits

💎 The client has acute neurological changes, including left-sided facial droop, left arm weakness, and left visual field deficit, which are consistent with a possible acute ischemic stroke.

💎 The NIH Stroke Scale score of 9 indicates measurable stroke deficits and supports the need for urgent stroke intervention.

💎 The last known well time was 0745, and the client arrived within a time-sensitive treatment window, making rapid assessment and treatment critical.

💎 The CT scan shows no hemorrhage, which is important because it supports further evaluation for ischemic stroke treatment.

💎 These stroke deficits are a priority because untreated cerebral ischemia can lead to permanent brain injury and worsening neurological function.

✅ The client’s hypertension

🔷 The client’s blood pressure remains elevated at 180/99 mm Hg, after initially being 200/102 mm Hg.

🔷 Hypertension is a priority because severe blood pressure elevation can worsen cerebral injury and increase the risk for intracerebral hemorrhage.

🔷 If thrombolytic therapy is being considered, blood pressure must be controlled within safe parameters before administration.

🔷 Ongoing hypertension also increases stress on damaged cerebral vessels and can worsen outcomes after stroke.

🔷 The nurse should continue frequent blood pressure monitoring and anticipate provider-directed blood pressure management.

❌ The client’s tachycardia

❌ The heart rate is 99 beats/min, which is not clinically significant tachycardia.

❌ The earlier heart rate of 100 beats/min is only borderline and not the priority compared with acute neurological deficits.

❌ The client’s hypoglycemia

❌ The capillary glucose is 119 mg/dL, which is within the expected range of 70 to 120 mg/dL.

❌ Hypoglycemia can mimic stroke symptoms, but this client’s glucose level does not support hypoglycemia as the cause.

❌ The client’s clotting disorder

❌ The clotting studies are within expected ranges: PT 11.2 sec, aPTT 30 sec, INR 1.1.

❌ These values do not indicate a clotting disorder and do not explain the client’s acute neurological deficits.

💎 Alteplase (tPA) dosing is based on the client's actual body weight, making an accurate current weight essential before administration.

💎 The standard dose for acute ischemic stroke is 0.9 mg/kg, with a maximum dose of 90 mg.

💎 An inaccurate weight can result in underdosing, which may reduce treatment effectiveness, or overdosing, which can increase the risk of bleeding complications, including intracranial hemorrhage.

💎 Because tPA is a high-alert medication, precise dosing calculations are critical to client safety.

💎 The nurse should obtain and verify the client's current weight before preparing and administering the medication.

❌ The client's current pain rating

❌ Pain assessment is important for overall care but does not determine the dose or eligibility for alteplase.

❌ The client reports only mild pain, and pain level is not a priority factor in tPA administration.

❌ The client's history of nicotine use

❌ Smoking history is a stroke risk factor but does not affect immediate alteplase dosing.

❌ The decision to administer tPA is based on stroke timing, imaging, neurological findings, and contraindications.

❌ The client's serum creatinine level

❌ Serum creatinine assesses kidney function and is not required for alteplase dose calculation.

❌ Alteplase dosing is weight-based rather than kidney function-based.

✅ New onset of aphasia

💎 The development of new aphasia after receiving alteplase is an unexpected neurological change and requires immediate follow-up.

💎 Aphasia indicates worsening neurological function and may suggest expansion of the stroke, decreased cerebral perfusion, or intracranial bleeding.

💎 Following tPA administration, any new neurological deficit should be treated as a potential emergency.

💎 The nurse should immediately stop any unnecessary activity, perform a neurological assessment, and notify the provider or stroke team.

💎 New neurological symptoms after thrombolytic therapy are concerning for complications such as intracerebral hemorrhage.

✅ Severe headache

🔷 A sudden severe headache following alteplase administration is a classic warning sign of possible intracranial hemorrhage.

🔷 Headache occurring with new neurological changes is especially concerning in a client receiving thrombolytic therapy.

🔷 Intracranial bleeding is one of the most serious complications of tPA treatment.

🔷 The nurse should anticipate urgent neurological reassessment and repeat brain imaging.

🔷 Severe headache should never be dismissed in a stroke client after thrombolytic therapy.

✅ Pain 9/10, headache

🟢 The client's pain increased from 0/10 initially to 9/10 at 1030, which represents a significant deterioration.

🟢 This severe pain is associated with the reported headache and supports concern for intracranial bleeding or worsening cerebral injury.

🟢 Sudden severe headache with high pain intensity is not an expected recovery finding after tPA administration.

🟢 The nurse should immediately report this change and continue close neurological monitoring.

🟢 Severe headache following thrombolytic therapy is considered a high-priority finding.

❌ Heart rate 90 beats/min

❌ A heart rate of 90 beats/min is within the expected adult range.

❌ The heart rate has improved from earlier values and does not indicate deterioration.

❌ Respiratory rate 18 breaths/min

❌ A respiratory rate of 18 breaths/min is within the normal range.

❌ There is no evidence of respiratory compromise or worsening respiratory status.

❌ Blood pressure 165/95 mm Hg

❌ Although elevated, the blood pressure has decreased from 200/102 mm Hg and 180/99 mm Hg.

❌ This trend suggests improvement rather than deterioration in blood pressure control.

❌ Oxygen saturation 99% on room air

❌ An oxygen saturation of 99% indicates excellent oxygenation.

❌ This finding does not suggest worsening neurological or respiratory status.

❌ NIH Stroke Scale 7

❌ The NIH Stroke Scale improved from 9 to 7.

❌ A lower NIHSS score indicates improved neurological function and reduced stroke severity.

✅ Temperature

💎 The client’s temperature is 101.8°F (38.7°C), which indicates a fever and suggests an active infection.

💎 In an older adult with UTI symptoms, fever raises concern that the infection may be worsening or spreading beyond the lower urinary tract.

💎 Fever combined with tachycardia, tachypnea, confusion, cloudy foul-smelling urine, and hematuria increases concern for systemic infection or early sepsis.

💎 This requires prompt follow-up because older adults can deteriorate quickly when infection becomes systemic.

💎 The nurse should anticipate urine culture, blood work, hydration support, and antibiotic therapy based on provider orders.

✅ Mental status

🔷 New or intermittent confusion in an older adult with a UTI is a priority finding.

🔷 The client is disoriented to date and time, and the family reports confusion over the last two days.

🔷 Acute mental status change can indicate delirium, which is often triggered by infection, dehydration, hypoxia, electrolyte imbalance, or sepsis in older adults.

🔷 This finding requires immediate follow-up because worsening confusion can increase fall risk, impair safety, and signal clinical decline.

🔷 The nurse should continue neurological checks, assess hydration and infection severity, and report worsening orientation changes promptly.

✅ Respiratory rate

🟢 The respiratory rate is 24/min, which is elevated and indicates tachypnea.

🟢 Tachypnea can be an early sign of systemic infection or sepsis because the body increases respiratory effort in response to fever, inflammation, or metabolic stress.

🟢 In this case, tachypnea occurs with fever, tachycardia, and altered mental status, making it more concerning.

🟢 A respiratory rate above 20/min is clinically significant in infection screening and should not be ignored.

🟢 The nurse should reassess breathing pattern, monitor oxygenation, and report this finding with the rest of the infection-related changes.

❌ Poor appetite

❌ Poor appetite is common in older adults with infection and can contribute to dehydration or weakness.

❌ It is important to monitor, but it is not as immediately concerning as fever, confusion, or tachypnea.

❌ The nurse should encourage fluids and nutrition as tolerated once urgent infection-related concerns are addressed.

❌ Poor intake may support the overall concern for illness but is not the highest-priority follow-up finding.

❌ It does not indicate immediate instability by itself.

❌ Blood pressure

❌ The blood pressure is 118/72 mm Hg, which is within an acceptable range.

❌ This does not show hypotension or shock at this time.

❌ In sepsis, falling blood pressure would be a late and serious sign, but that is not present here.

❌ The nurse should continue monitoring because infection can progress.

❌ This value does not require immediate follow-up compared with the abnormal findings.

❌ Oxygen saturation

❌ The oxygen saturation is 96% on room air, which is within the expected range.

❌ This indicates adequate oxygenation at the time of assessment.

❌ Although the respiratory rate is elevated, oxygen saturation is not currently low.

❌ The nurse should continue monitoring for changes.

❌ This finding does not require immediate follow-up right now.

✅ Blood pressure

💎 The client’s blood pressure has dropped from 118/72 mm Hg to 88/48 mm Hg, which indicates hypotension.

💎 Hypotension in a client with UTI, fever, tachycardia, tachypnea, confusion, and elevated WBC is highly concerning for urosepsis.

💎 Low blood pressure means the client may not be perfusing vital organs adequately, increasing the risk for shock, kidney injury, altered mental status, and organ failure.

💎 This is the first priority because circulation and tissue perfusion must be supported immediately.

💎 The nurse should anticipate rapid IV fluids, blood/urine cultures, broad-spectrum antibiotics, close vital-sign monitoring, and possible vasopressor support if hypotension persists.

✅ Serum lactic acid

🔷 The client’s lactic acid is 2.5 mmol/L, which is elevated above the normal range of 0.5 to 2 mmol/L.

🔷 Elevated lactate suggests impaired tissue perfusion and anaerobic metabolism, often seen in sepsis.

🔷 In this client, the elevated lactate combined with hypotension, fever, tachycardia, tachypnea, confusion, and leukocytosis strongly supports worsening systemic infection.

🔷 Lactic acid is important because it helps determine the severity of sepsis and guides urgent treatment decisions.

🔷 The nurse should report this finding promptly and anticipate sepsis protocol interventions.

❌ Temperature

❌ The temperature is 102.2°F (39°C), which confirms ongoing infection and requires treatment.

❌ However, fever is not the first priority compared with hypotension and elevated lactate, which indicate poor perfusion and possible sepsis progression.

❌ Serum potassium

❌ The potassium level is 4.0 mEq/L, which is within the expected range of 3.5 to 5.0 mEq/L.

❌ This value does not indicate an immediate electrolyte imbalance requiring priority intervention.

❌ Serum BUN/Cr

❌ The BUN is 22 mg/dL and creatinine is 1.5 mg/dL, both mildly elevated and concerning for possible dehydration or decreased kidney perfusion.

❌ These values require monitoring, but the immediate priority is correcting the hypotension and poor tissue perfusion causing kidney stress.

❌ Nausea

❌ Nausea is uncomfortable and contributes to poor oral intake, but it is not the most urgent threat.

❌ The client’s signs of urosepsis and hypotension must be addressed before symptom comfort measures.

💎 Autonomic dysreflexia is a potentially life-threatening emergency that occurs most commonly in clients with spinal cord injuries at or above T6.

💎 It results from an exaggerated sympathetic nervous system response to stimuli below the level of injury, such as a distended bladder, fecal impaction, pressure injury, or tight clothing.

💎 Manifestations include severe hypertension, bradycardia, pounding headache, flushing above the injury level, diaphoresis, and nasal congestion.

💎 If untreated, autonomic dysreflexia can lead to stroke, seizures, retinal hemorrhage, cardiac complications, and death.

💎 Immediate nursing interventions include sitting the client upright, removing the triggering stimulus, and monitoring blood pressure closely.

❌ Poikilothermia: A type of neurogenic shock that occurs in clients with a spinal cord injury above T6

❌ Poikilothermia is the inability to regulate body temperature, causing the body temperature to vary with the environment.

❌ It is not a form of neurogenic shock and is unrelated to the acute hemodynamic changes seen in neurogenic shock.

❌ Autonomic dysreflexia: Poikilothermia is the body's loss of ability to control and regulate body temperature

❌ This option incorrectly combines two different conditions into one statement.

❌ Poikilothermia and autonomic dysreflexia are separate complications with different causes and manifestations.

❌ Neutropenia: An abnormally low neutrophil count

❌ This statement is factually correct regarding the definition of neutropenia.

❌ However, neutropenia is a hematologic disorder and is not a specific complication associated with spinal cord injury, making option B the best answer.