How to Master One of the Hardest Parts of the ABNN SCRN Exam: Complications and Secondary Prevention

Ask Stroke Care Registered Nurse (SCRN) candidates which questions give them the most trouble, and complications and secondary prevention come up again and again. These questions rarely test one isolated fact. They ask you to spot an early warning sign in a stable-looking patient, pick the right priority action, and then choose the prevention strategy that fits that patient’s stroke cause.

Part of the challenge is that this topic doesn’t live in one place on the outline. It runs through the hyperacute, acute, post-acute, and prevention domains. Many nurses also know one end of the continuum far better than the other.

In this guide, we’ll break down what the outline covers, the core concepts and numbers to know, common traps, and a focused study plan.

Where Do Complications and Secondary Prevention Appear on the SCRN Exam?

The SCRN 2026 Candidate Handbook doesn’t have a single “complications” domain. Instead, the topic shows up in several places:

• Domain II, Hyperacute Care (42 items): Complication management and education, thrombolytic therapy, and medications.
• Domain III, Acute Care (42 items): Complication management, safety measures, therapeutic environment, and medications.
• Domain IV, Post-acute Care (19 items): Rehabilitation considerations such as spasticity and safety, plus medication management.
• Domain V, Primary and Secondary Preventative Care (19 items): Comorbidities and risk factors, prevention measures and social determinants of health, diagnostic tests, medication education and management, quality metrics, and community education.

These four domains account for 122 of the 150 scored items, so strength in this topic pays off across most of the exam.

What Complications Do You Need to Know?

Hemorrhagic Transformation and Post-Thrombolysis Bleeding

Symptomatic intracranial hemorrhage is the complication everyone fears after thrombolysis. Watch for a sudden headache, nausea or vomiting, a sharp rise in blood pressure, or a drop in level of consciousness or NIH Stroke Scale score.

• If these signs appear during an alteplase infusion, stop the infusion, notify the provider, and prepare for an emergent noncontrast CT.
• Standard neuro checks and vital signs after thrombolysis are every 15 minutes for 2 hours, every 30 minutes for 6 hours, then hourly until 24 hours.
• Keep blood pressure below 180/105 mmHg for 24 hours after treatment.
• Know that angioedema of the tongue and lips is another thrombolytic complication, more common in patients taking ACE inhibitors. Airway comes first.

Cerebral Edema and Increased Intracranial Pressure

After a large ischemic stroke, especially a large MCA infarct, edema typically peaks around days 2 to 5. Early signs include a declining level of consciousness, new or worsening headache, and vomiting. Later signs include pupil changes and Cushing’s triad (hypertension with a widening pulse pressure, bradycardia, and irregular respirations).

• Nursing measures include keeping the head of the bed at about 30 degrees, keeping the head and neck midline, avoiding hypotonic IV fluids, and treating fever.
• Medical options include hyperosmolar therapy (mannitol or hypertonic saline) and, for selected patients, decompressive hemicraniectomy.

Hemorrhagic Stroke Complications

• Intracerebral hemorrhage (ICH): Hematoma expansion is most likely in the first hours. For many patients with mild to moderate ICH, current AHA/ASA guidance supports lowering systolic pressure to a target of about 140 mmHg while avoiding drops below 130 mmHg. Anticoagulant reversal depends on the drug, such as four-factor prothrombin complex concentrate for warfarin, idarucizumab for dabigatran, and andexanet alfa for some factor Xa inhibitors.
• Aneurysmal subarachnoid hemorrhage (SAH): Delayed cerebral ischemia from vasospasm is most common between about days 3 and 14. Oral nimodipine (60 mg every 4 hours for 21 days) is given to improve outcomes. Watch sodium closely, because hyponatremia can come from cerebral salt wasting (treated with fluids and sodium) or SIADH (treated very differently).

Complications on the Stroke Unit

• Dysphagia and aspiration pneumonia: Perform a swallow screen before anything goes by mouth, including oral medications.
• Venous thromboembolism: Intermittent pneumatic compression is recommended for immobile stroke patients. Graduated compression stockings alone are not.
• Seizures, falls, pressure injuries, and urinary tract infections: Common preventable problems tied to immobility, neglect, and impulsivity.
• Post-stroke depression: Affects roughly one in three stroke survivors and can slow rehab progress. Screen for it.
• Hemiplegic shoulder pain and subluxation: Support the affected arm and never pull on it during transfers.
• Spasticity: Managed with positioning, stretching, splinting, and medications such as botulinum toxin or baclofen.

What Should You Know About Secondary Prevention?

Secondary prevention questions ask you to match the plan to the cause of the stroke. Key points from current AHA/ASA guidance include:

• Antiplatelet therapy: For noncardioembolic ischemic stroke, a single antiplatelet agent is standard long-term. For a minor ischemic stroke (NIHSS 3 or less) or high-risk TIA, aspirin plus clopidogrel started early (ideally within 24 hours) for 21 days, then a single agent, lowers early recurrence.
• Atrial fibrillation: Oral anticoagulation is indicated. Direct oral anticoagulants are generally preferred over warfarin for nonvalvular atrial fibrillation. Aspirin is not an adequate substitute.
• Blood pressure: A goal below 130/80 mmHg is recommended for most patients after stroke or TIA.
• Lipids: High-intensity statin therapy for atherosclerotic stroke, with an LDL goal below 70 mg/dL, adding ezetimibe if needed.
• Carotid stenosis: For symptomatic stenosis of 70% to 99%, carotid endarterectomy is recommended, ideally within 2 weeks when there is no contraindication.
• Lifestyle and social factors: Smoking cessation, diabetes control, physical activity, diet, limiting alcohol, and barriers such as medication cost, transportation, and health literacy.

Patient teaching ties it all together. Candidates should be able to teach the BE FAST warning signs (balance, eyes, face, arm, speech, time to call 911) and explain why each medication matters.

What Are the Most Common Traps in These Questions?

• Explaining away a neuro decline. Drowsiness on day 2 or 3 after a large stroke is cerebral edema until proven otherwise, not “just tired” or “just the medication.”
• Continuing the infusion. When bleeding signs appear during alteplase, stopping the infusion comes before calling for the CT.
• Giving oral medications before a swallow screen. The antiplatelet is important, but aspiration risk comes first. A failed screen means another route or a speech-language pathology evaluation.
• Choosing aspirin for atrial fibrillation. Cardioembolic stroke calls for anticoagulation, not antiplatelets.
• Keeping DAPT going indefinitely. Short-term dual antiplatelet therapy has a defined duration. Long-term use raises bleeding risk without added benefit for most patients.
• Mixing up SIADH and cerebral salt wasting. Fluid restriction in cerebral salt wasting can worsen hypovolemia and vasospasm risk in SAH.

How Would You Work Through a Sample Question?

Consider a question where a 68-year-old patient is 48 hours out from a right MCA ischemic stroke. On your morning assessment, the patient is harder to arouse, now opens eyes only to voice, and has a new right-sided headache. Blood pressure is 172/88 mmHg and heart rate is 64. You are asked for the priority nursing action.

Start by naming the problem. A large MCA stroke plus a declining level of consciousness at the 2-to-5-day mark points to cerebral edema. The answer choices might include documenting the change and reassessing in an hour, giving acetaminophen for the headache, raising the head of the bed to 30 degrees and notifying the provider, or lowering blood pressure with an as-needed antihypertensive.

Reassessing later delays care for a patient who may be herniating. Acetaminophen treats a symptom, not the cause. Aggressive blood pressure lowering can reduce perfusion to the penumbra and isn’t the first move.

The best answer is to position the patient to support venous drainage and escalate right away so imaging and treatment can follow.
Now consider a discharge question. A patient with a new diagnosis of atrial fibrillation had a small ischemic stroke and is going home on apixaban. Which statement shows a need for more teaching? “I’ll take my aspirin instead on days I forget the apixaban” is the red flag. Aspirin doesn’t replace anticoagulation, and missed doses of a direct oral anticoagulant leave the patient unprotected because the drug wears off quickly.

How Does This Topic Connect to Other SCRN Domains?

• Anatomy and pathophysiology: Knowing that a large MCA territory infarct swells more than a small lacunar stroke tells you who needs closer edema monitoring.
• Hyperacute care: The thrombolytic decisions you make in the first hour set up the bleeding and blood pressure monitoring you’ll do for the next 24 hours.
• Acute care: Swallow screening, VTE prevention, and early mobility are acute care tasks that prevent later complications.
• Post-acute care: Spasticity, depression, and fall risk shape which level of rehab a patient needs.
• Quality metrics: Many stroke quality measures, such as antithrombotic therapy at discharge, statins, and stroke education, are secondary prevention in action.

How Should You Study Complications and Secondary Prevention?

1. Build a timeline. List when each complication is most likely: bleeding in the first 24 hours after thrombolysis, edema around days 2 to 5, vasospasm around days 3 to 14 after SAH, and depression and spasticity in the weeks and months after.
2. Make a “cause to prevention” chart. Pair each stroke etiology (large artery atherosclerosis, cardioembolism, small vessel disease) with its prevention plan.
3. Memorize the key numbers. Blood pressure limits, DAPT duration, LDL and BP goals, the neuro check schedule, and the carotid stenosis threshold.
4. Practice priority questions. Answer by asking what’s most dangerous right now, then eliminate options that delay care.
5. Revisit in mixed sets. After a few days, test yourself on these topics mixed with the rest of the outline so you can spot complications when the question doesn’t label them.

In Pocket Prep, use Build Your Own Quiz to focus on the prevention and acute care subjects, then check your Missed Questions quiz each week to see which traps keep catching you.

Start Preparing for the ABNN SCRN Exam With Pocket Prep

Complications and prevention questions reward nurses who can think ahead, and that skill grows with practice. Pocket Prep’s ABNN SCRN practice questions offer 400 questions with detailed explanations that walk through the reasoning behind each answer. Try the Weakest Subject quiz to target your lowest domain, and Question of the Day to keep key facts fresh. You’re building the same judgment your patients count on, and you can bring it to exam day with confidence.