A nurse frequently treats patients in the 72-hour period after a stroke has occurred. The nurse would be most concerned about which of these assessment findings

A nurse frequently treats patients in the 72-hour period after a stroke has occurred. The nurse would be most concerned about which of these assessment findings?

1. INR is 3 seconds long
2. Heart rate is 110 beats per minute
3. Intracranial Pressure is 22 mm/Hg
4. Blood pressure is 140/80

1. INR is 3 seconds long
Incorrect – This is actually within a therapeutic range for clotting times for patients with coagulation risks. A normal INR is .9-1.2 seconds, while a therapeutic INR can be as high as 3.5 seconds.

2. Heart rate is 110 beats per minute
Incorrect – While tachycardia is a concern, general tachycardia without other associated symptoms would not pose an immediate danger, and is not of greater priority than the next answer.

Correct Answer: 3. Intracranial Pressure is 22 mm/Hg
Correct – The patient is at greatest risk for an increased ICP resulting from edema 72 hours after a stroke. A target ICP should be less than or equal to 15-20 mm/Hg

4. Blood pressure is 140/80
Incorrect – Blood pressure is often kept higher than usual following a stroke to maintain perfusion. Systolic BP higher than 180, or diastolic BP higher than 105, would be the upper limit and required intervention. 140/80 would not pose an immediate danger to the patient’s health.