Case Study — Neurology
Stroke NGN Case Study
A Next Gen NCLEX-style unfolding case. Read each step, commit to your own answer — out loud or on paper — and only then reveal ours. The six steps mirror the NCSBN Clinical Judgment Measurement Model exactly as the exam tests it.
15 min activity · Neurology
Educational use only. This case is a learning exercise with simplified values, not a treatment protocol — real stroke care follows provider orders, your facility’s stroke pathway, and current thrombolytic eligibility criteria. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
The Scenario
0905, ED arrival: Mrs. Chen, 76, is brought in by her daughter. At breakfast — about 0810, mid-conversation — her face “went crooked” and her coffee cup slipped from her right hand. She was completely normal before that; the daughter is certain because they were talking. History: atrial fibrillation (she stopped her anticoagulant months ago — “it caused bruising”), hypertension, osteoarthritis.
0910 Assessment
- HR 92 irregularly irregular · BP 178/96 · RR 18 · SpO₂ 96% RA · Temp 36.9°C
- Left facial droop; right arm drifts and falls within 5 seconds; right leg weak
- Speech slurred but intelligible; follows commands; anxious and tearful
- Swallow not yet assessed; daughter asks if she can give her mother water
Step 1 — Recognize Cues
Which findings are most relevant — and which matter most right now? List the cues you would flag before revealing.
▸Reveal answer
Most concerning cues: sudden focal deficits — facial droop, unilateral arm and leg weakness, slurred speech — the BE-FAST core. Sudden onset is the word that matters: strokes announce themselves in seconds to minutes.
The two golden details: a witnessed last known well of 0810 (a reliable clock makes her a potential thrombolytic candidate — it’s 0910 now, about one hour in) and atrial fibrillation off anticoagulation — the textbook setup for a cardioembolic ischemic stroke.
The cue hiding in a question: the daughter offering water. Nothing by mouth until a swallow screen passes — aspiration is one of the most preventable stroke complications.
Step 2 — Analyze Cues
What conditions could explain this picture — and what two tests must sort them before any treatment?
▸Reveal answer
Ischemic stroke (most supported): afib without anticoagulation makes an embolic clot the leading explanation for sudden unilateral deficits.
Hemorrhagic stroke: clinically indistinguishable at the bedside — which is exactly why the non-contrast head CT is the gatekeeper. Thrombolytics given into a bleed are lethal; nothing clot-busting happens before the scan.
Hypoglycemia — the great mimic: a fingerstick glucose is the other mandatory check; low sugar can produce focal deficits that resolve with dextrose. Hers is 132 — ruled out.
Also on the list: seizure with Todd’s paralysis, migraine variants — kept in mind, but a witnessed sudden onset in an afib patient doesn’t wait on them.
Step 3 — Prioritize Hypotheses
Rank your hypotheses and name the constraint that shapes everything.
▸Reveal answer
1. Acute ischemic stroke within the treatment window — probable, lethal to brain tissue by the minute (“time is brain”), and uniquely time-gated: IV thrombolysis is generally limited to within 3–4.5 hours of last known well, and large-vessel occlusions may also be thrombectomy candidates. Every workflow decision bends around that clock.
2. Hemorrhagic stroke — less likely but catastrophic to miss; the CT result flips the entire treatment plan, so it happens before anything else.
NGN logic: when one hypothesis carries a closing time window, speed itself becomes a priority — the evaluation is run in parallel (CT, labs, NIHSS together), not in sequence.
Step 4 — Generate Solutions
What should happen in the next 30 minutes? Draft your action list — include what you anticipate the stroke team will need.
▸Reveal answer
Immediate: activate the stroke alert; stat non-contrast head CT (the single rate-limiting step); fingerstick glucose (done — 132); NIHSS by a certified assessor; two IV lines; labs (CBC, coags, BMP) drawn without delaying the scan; accurate weight (tPA is weight-based); cardiac monitor (her afib is already showing).
Protect her while the clock runs: NPO until a swallow screen, head of bed per protocol, fall precautions, frequent neuro checks — and keep the daughter close: she is the time-of-onset witness and the history source.
Anticipate the eligibility screen: the team will run thrombolytic inclusion/exclusion criteria — recent surgery, bleeding history, anticoagulant use (she stopped hers — in this case that removes an exclusion), BP thresholds (generally must be below ~185/110 before tPA, managed with IV agents if needed).
Step 5 — Take Action
0950: CT shows no hemorrhage. NIHSS 11. The team gives IV thrombolysis at 1005 — just under two hours from onset. What does your nursing care look like for the next 24 hours?
▸Reveal answer
Intensive monitoring: neuro checks and vitals on the post-tPA schedule (typically q15min ×2h, then q30min ×6h, then hourly), with BP kept below ~180/105 — hypertension into a freshly lysed brain risks hemorrhagic conversion.
Bleeding vigilance: any neuro decline, new severe headache, vomiting, or acute hypertension = suspect intracranial hemorrhage → stop any infusing thrombolytic, stat CT, call the team. Also watch gums, IV sites, urine, and for angioedema (tongue/lip swelling — airway risk, higher in patients on ACE inhibitors).
Hold the blood thinners: no anticoagulants or antiplatelets for the first 24 hours post-tPA; no unnecessary lines, injections, or invasive procedures. Swallow screen before anything by mouth. Her afib anticoagulation conversation comes later — and matters enormously for preventing the next stroke.
Step 6 — Evaluate Outcomes
Next morning: NIHSS is down to 4 — the arm lifts and holds, speech is nearly clear, a mild facial droop remains. BP 152/84 on schedule, no bleeding. The daughter asks, “So she’s cured?” Which findings show success, and what still needs doing?
▸Reveal answer
Improving: the falling NIHSS is the objective marker — reperfusion salvaged threatened brain. No hemorrhagic conversion through the highest-risk window, BP controlled.
Still watching: the 24-hour follow-up CT before starting antithrombotics, swallow function before diet advancement, mood (post-stroke depression is common and undertreated), and mobility/fall risk as she re-engages.
Not resolved — and the honest answer to the daughter: the deficit is improving, not erased, and the cause is untreated. Secondary prevention is the discharge mission: restarting anticoagulation for afib (addressing the bruising concern that made her quit), BP control, rehab referrals, and BE-FAST teaching for the whole family — they caught this one fast; they should know exactly what they did right.
Debrief — The Pattern to Keep
- ✦Last known well is the most valuable history item in stroke — pin it down and protect the witness who knows it.
- ✦Glucose and CT before anything clot-related: one rules out the mimic, the other rules out the bleed.
- ✦Afib off anticoagulation is the classic embolic-stroke setup — and the secondary-prevention target afterward.
- ✦Post-tPA: BP below ~180/105, no antithrombotics ×24h, and any neuro change = stat CT.
- ✦NPO until the swallow screen passes — aspiration pneumonia is the preventable second injury.