Stroke (CVA) Cheat Sheet
Ischemic vs hemorrhagic stroke, FAST recognition, tPA rules and post-acute care — everything high-yield for the NCLEX-RN in one organized, expert-reviewed sheet.
What's in this cheat sheet
A stroke is a brain attack — every minute of delayed perfusion costs nearly 2 million neurons. This cheat sheet distills cerebrovascular accident (CVA) into four focused sections: how the two stroke types differ and present, the acute priorities that protect the airway and restore perfusion, the strict rules around fibrinolytic (tPA) therapy, and the post-acute rehabilitation that prevents complications and future strokes.
Pathophysiology & Assessment
Ischemic vs hemorrhagic mechanisms, TIA, top risk factors, FAST warning signs and left vs right hemisphere deficits.
Acute Interventions
Airway protection (NPO until swallow eval), CT to identify type and onset, and restoring perfusion for each stroke type.
Fibrinolytic Therapy (tPA)
The 4.5-hour window, absolute contraindications, and the #1 priority of watching for intracranial hemorrhage.
Post-Acute Care & Prevention
Fall and aspiration prevention, neglect and aphasia strategies, carotid procedures and secondary stroke prevention.
Key Takeaways
High-yield facts most likely to appear on the NCLEX-RN.
Hypertension is the #1 modifiable risk factor for stroke — always assess and manage blood pressure aggressively.
A sudden, severe "worst headache of my life" points strongly toward a hemorrhagic stroke.
tPA candidacy requires a head CT confirming ischemic stroke AND symptom onset less than 4.5 hours ago.
All stroke clients stay NPO until a formal swallow evaluation is completed — this protects against aspiration.
A decreased LOC during tPA infusion signals possible intracranial hemorrhage — stop the infusion and notify the HCP.
Ischemic strokes get clot-busters; hemorrhagic strokes get the opposite — strict BP control and surgical repair.
1. Pathophysiology & Assessment
A cerebrovascular accident (CVA) occurs when blood flow to the brain is disrupted, depriving brain tissue of oxygen.
Ischemic stroke (~87%)
A clot forms (thrombotic) or travels (embolic) into a cerebral artery, cutting off perfusion.
Hemorrhagic stroke (~13%)
A vessel ruptures (often an aneurysm), causing bleeding that raises ICP and compresses brain tissue.
TIA (transient ischemic attack)
A brief perfusion deficit that fully resolves within 24 hours — a major warning sign of future stroke.
Top risk factors
#1 hypertension (SBP >140), atrial fibrillation, diabetes, atherosclerosis, carotid stenosis, smoking, obesity.
FAST warning signs
- F — Facial drooping (one side droops or feels numb)
- A — Arm weakness or drift when both arms are raised
- S — Speech difficulty, slurred or hard to understand
- T — Time to call emergency services immediately
Ischemic vs Hemorrhagic stroke
| Feature | Ischemic | Hemorrhagic |
|---|---|---|
| Mechanism | Clot blocks artery | Vessel ruptures / bleeds |
| Frequency | ~87% of strokes | ~13% of strokes |
| Onset | Gradual or sudden | Sudden, severe |
| Treatment | tPA (clot buster) | Surgery, NOT tPA |
| BP goal | Permissive HTN: SBP 160–180 | Strict control: SBP <160 |
| Headache | Not typical | "Worst headache of my life" |
Left vs Right hemisphere stroke
| Left-sided | Right-sided |
|---|---|
| Right-side body weakness | Left-side body weakness |
| Language & speech deficits (aphasia) | Spatial neglect (left side) |
| Cautious, slow behavior | Impulsive, poor judgment |
| Depression more common | Emotional lability |
| "L" = Language | "R" = Recklessness |
2. Acute Interventions
Priority order: protect the airway → identify stroke type & onset → restore cerebral perfusion.
Step 1 — Protect the airway
- Keep client NPO until a formal swallow evaluation is completed — prevents aspiration
- Watch for coughing, choking, or a wet/gurgling voice when swallowing
Step 2 — Identify type & timing
- Immediate head CT distinguishes ischemic from hemorrhagic
- Onset <4.5 hr → possible tPA candidate if ischemic
- Check blood glucose — hypoglycemia can mimic stroke
- Frequent neuro checks using the NIH Stroke Scale (NIHSS)
Step 3 — Restore perfusion
Ischemic
Give tPA if onset <4.5 hr; prepare for embolectomy; permissive HTN (SBP 160–180) for the first 48 hr.
Hemorrhagic
↓ ICP (HOB up, minimize stimulation), strict BP control (SBP <160), seizure precautions, NO anticoagulants, prepare for surgery.
3. Fibrinolytic Therapy (tPA)
Tissue plasminogen activator (IV alteplase) dissolves clots and must be given within 4.5 hours of ischemic stroke onset.
Before starting tPA
- Screen thoroughly for contraindications — hemorrhage risk
- Establish at least 2 IV access lines before infusion
- Complete all invasive procedures FIRST (NG tube, urinary catheter) to minimize bleeding
During tPA infusion
- #1 priority: monitor for signs of intracranial hemorrhage (ICH)
- STOP infusion & notify HCP for ↓ LOC, sudden hypotension, new N/V, or severe headache
- Frequent vital signs and neuro checks throughout
- Give IV labetalol if SBP exceeds 180 mmHg
Absolute contraindications for tPA
| Do NOT give tPA if the client has... |
|---|
| Active bleeding anywhere in the body |
| Current or prior intracranial hemorrhage |
| Aortic dissection or cerebral vascular malformation |
| Head trauma, cranial surgery, or ischemic stroke within 3 months |
| Severe uncontrolled hypertension or known bleeding disorder |
4. Post-Acute Care & Prevention
Fall & aspiration prevention
- Ambulate a client with hemiparesis by standing on the WEAK side so they lead with the strong side
- High-Fowler position during all meals and oral intake
- Place food on the unaffected side of the mouth to prevent pocketing
- Dysphagia → thickened liquids and a soft or pureed diet
Vision, neglect & aphasia
- Dress the affected side first; approach from the unaffected side
- Encourage head scanning and rotate the meal tray for left-sided neglect
- Aphasia: ask yes/no questions, speak at normal volume, give one-step instructions, allow extra time
- Expressive (Broca) = understands but can't speak; Receptive (Wernicke) = speaks but can't understand
Secondary stroke prevention
- Control BP consistently — the single most impactful modifiable factor
- Antiplatelets (aspirin, clopidogrel) after ischemic stroke; anticoagulants for atrial fibrillation
- Statins to stabilize plaque; smoking cessation; heart-healthy low-sodium diet
- Carotid angioplasty/stent: monitor neuro status, report any change in LOC (possible stent occlusion)
Stroke Self-Test
6 quick questions — answers reveal after you submit.
Q1. A client arrives with sudden right-sided weakness and slurred speech that began 2 hours ago. The CT confirms an ischemic stroke. What intervention does the nurse anticipate?
Q2. A client reports a sudden, severe headache described as "the worst of my life" with vomiting. Which type of stroke does the nurse most suspect?
Q3. Which action is the priority for a newly admitted stroke client before allowing any oral intake?
Q4. During a tPA infusion, the client becomes difficult to arouse with a decreasing level of consciousness. What is the nurse's first action?
Q5. A client has a right-hemisphere stroke. Which nursing intervention is most appropriate?
Q6. When ambulating a client with left-sided hemiparesis, where should the nurse stand?
Answered 0 / 6 — unanswered count as incorrect.