Stroke for exams: recognition, the time window and what to do first

Recognising stroke

FAST stands for Face drooping, Arm weakness, Speech difficulty and Time to act. The American Heart Association materials note that it can miss isolated vision, balance or sensory problems, which is why BE-FAST adds Balance and Eyes. Sudden onset is the key feature.

This is exam-preparation revision, not clinical guidance. In practice, follow your own organisation’s policies and the current guideline, and check doses and thresholds against them.

Mimics worth knowing

Low blood glucose is the classic mimic. That is why a glucose check is part of the first minutes. Other mimics include seizure with a post-ictal state, migraine and infection. You do not need to rule them out yourself, but you need to check glucose and report your findings.

First actions

Exams reward this order, adjusted to your setting.

1. Call the emergency or stroke team. Use the stroke pathway your organisation has.
2. Note the time the patient was last known well, not the time you found them. This sets treatment eligibility.
3. Check airway, breathing and circulation. Give oxygen only if oxygen saturation is low, as your protocol directs.
4. Check blood glucose and treat if low. The 2019 American Heart Association and American Stroke Association guideline states that glucose assessment must come before starting intravenous alteplase.
5. Keep the patient nil by mouth until a swallow screen has been done, and position for safety.
6. Prepare for urgent brain imaging, which separates ischaemic from haemorrhagic stroke.

The treatment window

The same guideline states that time from symptom onset to intravenous alteplase should be as short as possible and not more than 4.5 hours, in selected patients. Some sources describe 3 hours as the licensed window, with 4.5 hours for selected patients. Eligibility is decided by the doctor, with imaging. Mechanical thrombectomy for certain large vessel blockages has its own, longer windows, which differ by guideline, so we do not give them here.

Nursing care themes

Questions often test the following.

• Neurological observations at the frequency in the protocol, and escalating a change in consciousness.
• Swallow screening before any food, drink or oral medicine.
• Blood pressure targets, which depend on whether thrombolysis is planned. Do not lower pressure on your own.
• Positioning, skin care and early mobilisation as the team advises.
• Communication with a patient who has aphasia: short questions, time, and checking understanding.

How it links to other topics

A patient with atrial fibrillation is at higher risk, so read the ECG guide. Consent and capacity often appear in stroke scenarios, see ethics and consent. For the question style, practise in the question bank.

A worked exam scenario

Invented for teaching. A relative finds a man with slurred speech and a drooping face at 9 am. He was well when he went to bed at 10 pm. What is the time last known well, and what is the first nursing action when he arrives?

The time last known well is 10 pm, not 9 am. The first actions are airway and breathing checks, a call to the stroke team, a glucose check and preparation for urgent imaging. Giving him a drink or aspirin before a swallow screen and imaging are common wrong answers, because a swallow problem is likely and imaging decides the type of stroke.

Talking with the patient and family

Speak clearly and slowly, give one instruction at a time and allow time to answer. Explain what is happening and what happens next. Ask the family for the time last known well, medicines and any previous events. Keep the patient safe from falls. Exams reward calm, clear communication and early escalation over long explanations.

Ischaemic or haemorrhagic

Imaging separates a blockage from a bleed, and treatment differs. Thrombolysis is for ischaemic stroke only, after imaging and a medical check of eligibility. A sudden severe headache, vomiting, a falling level of consciousness or a patient on anticoagulants raises concern for bleeding. Your job in an exam answer is to recognise the emergency, escalate, support the airway and keep the patient safe, not to decide the type. Questions that ask which medicine to give before imaging are usually testing whether you know to wait.

Frequently asked questions