Study topic
Stroke and neuro assessment
NCLEX stroke and neuro chapter: last-known-well timing, dysphagia aspiration precautions, pupil and GCS cues, pain assessment honesty, and autonomic dysreflexia.
Stroke and spinal-cord items reward the nurse who protects the airway, knows the clock, and treats a pounding headache after T6 injury as an emergency, not a migraine.
Acute stroke: clock and airway
Sudden one-sided weakness, facial droop, or speech change is a stroke pathway until imaging and the neurologist say otherwise. The single most important historical fact for ischemic treatment is when the client was last known well.
- Activate the stroke response. ABCs and glucose check happen early (hypoglycemia mimics stroke).
- CT rules out hemorrhage before IV thrombolysis decisions.
- Know facility contraindications for alteplase (recent surgery, active bleed, uncontrolled severe hypertension, etc.) as listed in the protocol.
Dysphagia and aspiration precautions
- Keep NPO until a swallow screen or speech evaluation clears oral intake.
- Feed upright (high Fowler's); keep upright after meals as ordered.
- Use ordered consistency (thin vs thickened). No straws unless cleared.
- Have suction ready. Chin-tuck or other strategies only as taught for that client.
Neuro and pain assessment
| Finding | Meaning |
|---|---|
| Falling LOC, new confusion, or sudden deficit growth | Report now — evolving neuro emergency |
| New unequal, fixed, or poorly reactive pupils | Report now — possible rising ICP or herniation pathway |
| GCS eye / verbal / motor | Structured LOC tool; know what each subscale scores |
| Name, place, date questions | Orientation assessment |
| Pain 8/10 while lying quietly | Believe the report; treat the number the client gives |
| Infant who cannot self-report | Use a behavioral pain scale, not an adult numeric scale alone |
Spinal cord injury complications
Autonomic dysreflexia
In clients with injury typically at or above T6, a noxious stimulus below the injury can trigger massive hypertension. Classic picture: pounding headache, BP sky-high, bradycardia, flushing/sweating above the injury.
- Sit the client up / elevate the head of bed.
- Loosen tight clothing and abdominal binders.
- Check bladder (kinked catheter, distention) and bowel/skin triggers.
- Notify the provider; give ordered antihypertensives if the trigger cannot be cleared quickly.
Safety
Do not lay an autonomic dysreflexia client flat while the blood pressure is critically high. Sitting up is part of the first response.
Neurogenic shock
Early after SCI: hypotension with bradycardia and warm dry skin below the injury from lost sympathetic tone. This is not the cool-clammy hypovolemic picture.
Priority map
| Picture | First move |
|---|---|
| Sudden weakness + slurred speech | Stroke pathway; get last known well |
| Post-stroke oral intake request | Swallow screen first; NPO until clear |
| Unequal/fixed pupils + declining LOC | Escalate immediately |
| T4 injury + BP 220 + pounding headache | AD: sit up, find trigger, notify |
| Pain 8 while calm-faced | Treat the reported pain |
Must know
- 1For suspected ischemic stroke, last known well / symptom onset time drives thrombolysis eligibility. Get it accurately.
- 2NPO until swallow screen is passed after stroke. High Fowler's for oral intake, chin tuck as taught, thickened liquids if ordered, suction ready.
- 3Decreasing LOC, new unequal/fixed pupils, or sudden neuro decline: report immediately.
- 4Believe the client's pain report even if they look calm. Pain is what the client says it is.
- 5GCS assesses eye, verbal, and motor response. Orientation questions assess person/place/time.
- 6Infant pain: use a behavioral tool (e.g., FLACC-style), not a 0–10 self-report.
- 7Autonomic dysreflexia (injury usually at or above T6): pounding headache, severe hypertension, bradycardia, flushing above injury. Sit up, loosen clothing, find and remove the trigger (often bladder/bowel), notify.
- 8Neurogenic shock after SCI: hypotension + bradycardia + warm dry skin below injury.
- 9Casted limb: report severe pain, pallor, coolness, delayed refill, numbness (compartment/neurovascular danger).
Memory hooks
Time is brain — know last well
Thrombolysis decisions start with when the client was last known normal. Guessing the clock wastes the window.
Sit up, find the full bladder
Autonomic dysreflexia: elevate the head, loosen constricting items, then hunt bladder, bowel, and skin triggers.
NPO until they pass the sip
After stroke, nothing by mouth until a swallow screen clears them. Aspiration is silent until it is pneumonia.
How it's tested
Stems ask for last-known-well, aspiration precautions after dysphagia, unequal pupils, or a T4 client with a pounding headache and BP 220. Distractors feed a freshly stroked client, lay an AD client flat, or dismiss a quiet client's pain score of 8.