A nurse is assessing a client admitted to the hospital after sudden neurological deficits. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress

Rationale for Correct Choices Cerebral vascular accident (CVA / stroke): The client presents with sudden unilateral facial droop, left-sided weakness, impaired speech, blurred vision, and confusion. Imaging (CT and MRI) confirms a recent infarction in the left frontal lobe, consistent with an ischemic stroke. Initiate administration of thrombolytic therapy: Administering tPA promptly within the therapeutic window can dissolve the clot and restore cerebral perfusion, reducing neurological deficits. Elevate the head of the bed: Elevating the head 30 degrees promotes venous drainage, decreases intracranial pressure, and improves cerebral perfusion without compromising blood flow to the ischemic area. Blood pressure treds: Careful monitoring is essential because elevated blood pressure can worsen cerebral edema or increase risk of hemorrhagic transformation after tPA administration. Neurological status assessments using GCS: Frequent neurological assessments detect early signs of deterioration or complications from stroke or thrombolytic therapy. Rationale for Incorrect Choices Brain ischemia due to hypoxia: While ischemia occurs, this is secondary to a thrombotic event, not generalized hypoxia. The clinical presentation and imaging confirm a localized infarct. Acute spinal cord injury: Symptoms are primarily motor and sensory deficits below the injury site; facial droop and speech impairment point to a brain lesion, not spinal cord injury. Intracranial hemorrhage: CT scan shows hypodensity (ischemia) rather than hyperdensity (bleeding), making hemorrhagic stroke unlikely. Provide a warm compress for client comfort: Comfort measures are not the priority in acute ischemic stroke management. Administer oxygen therapy: Oxygen is only indicated if saturation drops below normal; this client maintains 96% on room air. Start an intravenous fluid bolus: IV fluids are not a priority unless hypovolemia is present; overhydration can worsen cerebral edema. Pain level / Presence of periorbital ecchymosis: Not primary concerns in acute ischemic stroke assessment and monitoring.