An older male adult comes to the emergency department after falling at home, and he reports that he cannot walk without losing his balance. Which of the following steps should the nurse implement for this patient?
a. Arrange to transfer him to radiology immediately.
b. Determine symptom onset or when he fell at home.
c. Organize the tissue plasminogen activator (tPA) infusion.
d. Perform a comprehensive neurological assessment.
B
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A Incorrect. A patient who is seen with clinical indicators of a stroke will need a computed tomography (CT) scan to differentiate between a thrombotic and a hemorrhagic stroke because the type of stroke determines the therapeutic course. Even so, the time of symptom onset is a vital piece of information that must be determined before the trip to radiology because tPA is usually administered in the radiology suite.
B Correct. The nurse determines when the symptoms appeared first or the time of the fall to determine if sufficient time is left to administer tPA because, if it is indicated, it must be administered within 3 hours of symptom onset.
C Incorrect. Administration of tPA can be contraindicated for this patient, so preparation of this infusion is delayed until the type of stroke and plan of care is determined.
D Incorrect. 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.
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