A client with sudden visual changes is evaluated for ischemic CVA. Which initial nursing action is most appropriate?

• A. Determine when symptoms began and if it improved or worsened since onset.
• B. Administer aspirin immediately
• C. Check blood glucose
• D. Call the ophthalmology team

Answer: (A)

In suspected ischemic stroke, time drives every treatment decision. The first thing to determine is exactly when symptoms began and whether they have changed since onset. That onset timing tells you whether the patient may be within the window for reperfusion therapies like thrombolytics and guides rapid activation of the stroke protocol and imaging. Checking blood glucose remains essential to rule out hypoglycemia that can mimic stroke, but it doesn’t determine treatment eligibility as directly as onset time. Administering aspirin right away isn’t the initial move because antiplatelet therapy is typically started after imaging confirms there’s no hemorrhage. Calling the ophthalmology team isn’t the immediate priority when brain ischemia is suspected.