Evidence-Based clinical practice recommendations of nursing care of acute stroke patient includes all of the… - GMCH Chandigarh - 2022

GMCH Chandigarh - 2022

Medical Surgical Nursing

Medium

Appeared in: GMCH Chandigarh - 2022

Explanation

The correct option is an exception because it describes a passive action ('Observe the patient'), which is contrary to the principles of acute stroke management.
Evidence-based stroke care is defined by rapid, active, and time-sensitive interventions aimed at preserving brain function.
While nurses do observe patients, this is part of a continuous, active monitoring process (e.g., frequent neurological checks, vital signs) that guides immediate interventions, not a standalone, passive recommendation.

Option A: This is a core component of stroke care. Rapid identification, often using tools like BE-FAST (Balance, Eyes, Face, Arms, Speech, Time), and immediate triage are the first steps to activating the stroke system and initiating treatment.
Option B: This is the primary goal of acute stroke management. Enabling time-critical treatments like intravenous thrombolysis (tPA) or mechanical thrombectomy is crucial for improving patient outcomes.
Option D: This is a key evidence-based recommendation. Transferring patients to a dedicated acute stroke unit has been proven to reduce mortality and long-term disability through specialized, coordinated care.

Visual 1: Flowchart - The Acute Stroke Care Pathway. This visual can illustrate the sequence of events from symptom onset to treatment, highlighting time-critical decision points like 'Door-to-CT' and 'Door-to-Needle'.
Visual 2: Infographic - The BE-FAST acronym. This provides a simple, memorable tool for rapid stroke identification, explaining what to look for in terms of Balance, Eyes, Face, Arms, and Speech.

Clinical Relevance

Nursing practice connection: Use the key finding related to Evidence-based nursing management of acute ischemic stroke to guide bedside assessment, documentation, and the next nursing action.
Nurses are central to the 'stroke chain of survival,' playing a vital role in rapid assessment, administering time-sensitive medications, and continuous monitoring for changes in neurological status.
Key time targets are critical in stroke care: Door-to-CT scan should be within 25 minutes, and Door-to-Needle (tPA administration) should be within 60 minutes of arrival.
Patient safety is paramount. Nurses must perform a swallow screen before giving anything by mouth (NPO status) to prevent aspiration pneumonia, a common and serious complication of stroke.

How to Approach the Question

First, identify the question type. This is a negative-lead-in question because it uses the word 'except'. Your goal is to find the option that is NOT a standard practice.
Recall the core principle of acute stroke care: 'Time is Brain'. This principle emphasizes urgency and active intervention.
Evaluate each option against this principle. Ask yourself, 'Is this a rapid, active, and evidence-based intervention for acute stroke?'
Option A (Rapid identification), Option B (Time-critical treatment), and Option D (Transfer to stroke unit) are all active, time-sensitive interventions.
Option C ('Observe the patient') is a passive statement. While observation is part of nursing, it doesn't represent the specific, urgent actions required in the acute phase.
The option that is inconsistent with the core principle of active, urgent care is the correct answer.

Concept Tested & Keywords

Concept Tested: Evidence-based nursing management of acute ischemic stroke.
Stem keywords: acute stroke, nursing care, evidence-based, clinical practice
Lead-in keywords: except
Negative lead-in flag: The question asks for the exception among the given options.

QkcXmH15RzCdtVouJL90d1