Abel – Case Study 4 of 6
SATA
The nurse is implementing care for the client with acute stroke. Which actions are appropriate? Select all that apply.
Rationale
✅ 1. HOB 0–15° — promotes blood flow to ischemic penumbral tissue pre-CT
✅ 2. NIH Stroke Scale — standardized baseline; guides treatment and monitors progression
❌ 3. tPA before CT — if hemorrhagic, tPA causes catastrophic fatal bleeding
✅ 4. NPO + dysphagia screening — stroke causes dysphagia; aspiration pneumonia is a leading complication
✅ 5. GCS + pupils — detects early deterioration or herniation requiring immediate escalation
✅ 6. Prepare tPA if eligible — standard of care within 3–4.5 hrs; review DVT and seizure history as contraindications
✅ 1. HOB 0–15° — promotes blood flow to ischemic penumbral tissue pre-CT
✅ 2. NIH Stroke Scale — standardized baseline; guides treatment and monitors progression
❌ 3. tPA before CT — if hemorrhagic, tPA causes catastrophic fatal bleeding
✅ 4. NPO + dysphagia screening — stroke causes dysphagia; aspiration pneumonia is a leading complication
✅ 5. GCS + pupils — detects early deterioration or herniation requiring immediate escalation
✅ 6. Prepare tPA if eligible — standard of care within 3–4.5 hrs; review DVT and seizure history as contraindications
