An older man comes to the emergency department after falling at home, and he reports that he cannot walk without losing his balance. Which steps should the nurse implement for this patient?

Question

a. Arrange to transfer him immediately to the radiology department.
b. Determine symptom onset or when he fell at home.
c. Organize the reperfusion tissue plasmino-gen activator (tPA) infusion.
d. Perform a comprehensive neurologic as-sessment.

Answer 1

B
The nurse determines when the symptoms first appeared or the time of the fall to determine whether sufficient time is left to administer reperfusion tPA; if indicated, tPA must be adminis-tered within 3 hours of symptom onset. A patient with clinical indicators of a stroke will need a computed tomographic (CT) scan to differentiate between a thrombotic stroke and a hemorrhagic stroke; the type of stroke will determine the therapeutic course. The time of symptom onset is a vital piece of information that must be determined before the patient is referred to the radiology department because tPA is usually administered in the radiology suite. Administering tPA can be contraindicated for this patient; therefore the preparation of this infusion is delayed until the type of stroke and the plan of care are determined. The nurse will not have enough time to complete a comprehensive assessment and thus will perform a focused assessment in preparation for the trip to radiology.