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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A reason: Isolated systolic hypertension is not a result of end-organ damage from chronic hypertension, but rather a risk factor for it. Isolated systolic hypertension is a condition where the systolic blood pressure is elevated (>140 mmHg) while the diastolic blood pressure is normal (<90 mmHg). It is common in older adults due to the stiffening of the arteries, and can increase the risk of cardiovascular and cerebrovascular events.
Choice B reason: Atrial fibrillation is a result of end-organ damage from chronic hypertension. Atrial fibrillation is an irregular and often rapid heart rate that can cause poor blood flow and increase the risk of stroke and heart failure. Chronic hypertension can damage the heart muscle and the electrical system of the heart, leading to atrial fibrillation.
Choice C reason: Renal insufficiency is a result of end-organ damage from chronic hypertension. Renal insufficiency is a condition where the kidneys are unable to filter waste and fluid from the blood adequately. Chronic hypertension can damage the blood vessels and the nephrons of the kidneys, leading to renal insufficiency.
Choice D reason: Stroke is a result of end-organ damage from chronic hypertension. Stroke is a sudden interruption of blood supply to the brain, causing brain cell death and neurological deficits. Chronic hypertension can damage the blood vessels in the brain, making them prone to rupture (hemorrhagic stroke) or blockage (ischemic stroke).
Choice E reason: Cardiac disease is a result of end-organ damage from chronic hypertension. Cardiac disease is a broad term that encompasses various disorders of the heart, such as coronary artery disease, heart attack, heart failure, and cardiomyopathy. Chronic hypertension can damage the heart by increasing the workload and the oxygen demand of the heart, causing the heart to enlarge and weaken over time.
Correct Answer is A
Explanation
Choice A reason: Crushing chest pain is the classic sign of an AMI, but it can be absent in some older men with an AMI. This is because older men may have a reduced pain perception due to aging, diabetes, or other conditions that affect the nerve endings. Older men may also have atypical or silent AMIs, which do not cause chest pain or other obvious symptoms.
Choice B reason: Epigastric burning is not a classic sign of an AMI, but it can be a symptom of an AMI in some older men. Epigastric burning may be mistaken for indigestion, heartburn, or gastritis, but it can also indicate ischemia or injury to the lower part of the heart.
Choice C reason: Dyspnea and fatigue are not classic signs of an AMI, but they can be symptoms of an AMI in some older men. Dyspnea and fatigue may be attributed to aging, deconditioning, or other chronic diseases, but they can also indicate reduced oxygen supply to the heart and the body.
Choice D reason: Vague complaints are not classic signs of an AMI, but they can be symptoms of an AMI in some older men. Vague complaints may include anxiety, restlessness, nausea, dizziness, or weakness, which may be overlooked or dismissed as minor ailments, but they can also indicate a serious cardiac event.
Choice E reason: None of the above is not the correct answer, as there is one choice that is the classic sign of an AMI that can be absent in an older man with an AMI.
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