Nursing care of a patient during the acute phase of a stroke does not include which response below?

The response regarding initiating t-PA (tissue Plasminogen Activator) is an important consideration in the management of acute ischemic stroke. Administering t-PA is a critical time-sensitive intervention that can help dissolve the blood clot causing the stroke, but it must be done within a strict time frame, typically within 3 to 4.5 hours of symptom onset, depending on the protocol and guidelines being followed. While it is essential to assess eligibility for t-PA administration during the acute phase, this intervention does not typically fall under the nursing care responsibilities. Instead, the decision to initiate t-PA is made by the medical team based on specific criteria, and it's essential that nurses focus on monitoring and supportive care rather than acting to initiate this treatment.

Monitoring vital signs closely, assessing for symptoms of increased intracranial pressure, and performing a thorough head-to-toe assessment are all necessary nursing responsibilities during the acute phase of stroke management. These actions provide critical information about the patient’s condition and help guide further treatment and interventions.