A home health nurse is completing an admission on a client who recently experienced a transient ischemic attack (TIA). During the assessment, the client begins to report a severe headache and numbness in the left arm. Which action should the nurse take initially?

Call 9-1-1.

Determine if the client has a history of migraine headaches.

Give the client a dose of acetaminophen.

Assure the client the symptoms will resolve within 24 hours.

None of the above.

Answer and Explanation

The Correct Answer is A

Choice A reason: Call 9-1-1 is the best action to take initially, as the client may be having another TIA or a stroke. The nurse should act fast and seek emergency medical attention for the client, as timely intervention can prevent permanent brain damage and disability.

Choice B reason: Determine if the client has a history of migraine headaches is not the best action to take initially, as it may delay the diagnosis and treatment of a possible TIA or stroke. Migraine headaches can cause similar symptoms to a TIA or stroke, but they are not the same condition and require different management.

Choice C reason: Give the client a dose of acetaminophen is not the best action to take initially, as it may mask the symptoms of a possible TIA or stroke and interfere with the blood clotting process. Acetaminophen is a pain reliever and a fever reducer, but it is not effective for treating a TIA or stroke.

Choice D reason: Assure the client the symptoms will resolve within 24 hours is not the best action to take initially, as it may give the client a false sense of security and prevent them from seeking urgent medical care. A TIA or stroke is a medical emergency that requires immediate attention, as the symptoms may worsen or become permanent.

Choice E reason: None of the above is not the correct answer, as there is one choice that is the best action to take initially.

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Correct Answer is A

Explanation

Choice A reason: Older adult declines company, is preoccupied with lethal weapons is the highest risk factor for suicide, as it indicates social isolation, hopelessness, and suicidal intent. The older adult may be suffering from depression, anxiety, or other mental health issues that impair their quality of life and increase their likelihood of harming themselves.

Choice B reason: Liver failure is due to alcohol abuse, older adult is popular at meals is not the highest risk factor for suicide, as it does not indicate suicidal ideation or behavior. The older adult may have a chronic medical condition that affects their liver function, but they may also have a supportive social network and coping skills that reduce their risk of suicide.

Choice C reason: Refuses to allow a large, extended family to help him is not the highest risk factor for suicide, as it does not indicate suicidal ideation or behavior. The older adult may have a preference for independence and autonomy, or they may have a strained relationship with their family. However, they may also have other sources of support and meaning in their life that lower their risk of suicide.

Choice D reason: The older adult had an overdose of acetaminophen 20 years ago; is in a sewing group is not the highest risk factor for suicide, as it does not indicate current suicidal ideation or behavior. The older adult may have a history of a suicide attempt, but they may also have recovered from their past crisis and found a positive outlet for their emotions and interests in the sewing group.

Choice E reason: None of the above is not the correct answer, as there is one choice that indicates the highest risk for suicide.

A. Corn B. White bread C. Baked beans D. Broccoli

Correct Answer is D

Explanation

Choice A reason: Corn is not a food that does not increase blood glucose. Corn is a starchy vegetable that contains carbohydrates, which can raise blood glucose levels.

Choice B reason: White bread is not a food that does not increase blood glucose. White bread is made from refined flour, which has a high glycemic index and can spike blood glucose levels.

Choice C reason: Baked beans are not a food that does not increase blood glucose. Baked beans are high in sugar and carbohydrates, which can affect blood glucose levels.

Choice D reason: Broccoli is a food that does not increase blood glucose. Broccoli is a non-starchy vegetable that is low in carbohydrates and high in fiber, which can help regulate blood glucose levels.

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A home health nurse is completing an admission on a client who recently experienced a transient ischemic attack (TIA). During the assessment, the client begins to report a severe headache and numbness in the left arm. Which action should the nurse take initially?

Nursing Test Bank

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Which assessment finding of an older adult living in an assisted-living facility indicates the highest risk for suicide?

Correct Answer is A

Explanation

When teaching a client about foods that do not increase blood glucose, which should the nurse include?

Correct Answer is D

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