Stroke and Cerebrovascular Disorders · NCLEX Exam

When documenting the time of onset of stroke symptoms, what is the nurse's best action?

  1. Record the time when the client arrived in the ED
  2. Estimate the time when the symptoms were first noticed
  3. Record the exact time the client was last seen at baseline (normal)
  4. Document the time when the CT scan was performed
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Correct answer: Record the exact time the client was last seen at baseline (normal)

Recording the “last known well” time (when the client was at baseline) is essential for determining eligibility for thrombolytic therapy in an Ischemic stroke.

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