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","B"]

Explanation

Choice A reason: This assessment is reliable in the older adult because the skin turgor at the sternum is less affected by age-related changes in skin elasticity and hydration than other sites, such as the forearm or the hand. The skin turgor at the sternum can indicate the fluid status of the older adult, as well as the presence of dehydration or edema.

Choice B reason: This assessment is reliable in the older adult because orthostasis, or a drop in blood pressure when changing positions, is a common condition in this population. Orthostasis can be caused by various factors, such as medications, dehydration, anemia, or autonomic dysfunction. Orthostasis can increase the risk of falls, dizziness, syncope, or cardiovascular complications in the older adult.

Choice C reason: This assessment is not reliable in the older adult because sunken eyes are not a specific sign of dehydration in this population. Sunken eyes can be a normal age-related change in the facial structure, or a result of other factors, such as weight loss, malnutrition, or chronic illness. Sunken eyes can also be influenced by the lighting, the angle of observation, or the presence of glasses or contact lenses.

Choice D reason: This assessment is not reliable in the older adult because decreased urine output is not a sensitive indicator of dehydration in this population. Decreased urine output can be influenced by various factors, such as renal function, fluid intake, medications, or environmental conditions. Decreased urine output can also be a sign of other conditions, such as urinary tract infection, urinary retention, or renal failure.

A. Fecal impaction B. Diarrhea C. Constipation D. Hemorrhoids E. None of the above

Correct Answer is B

Explanation

Choice A reason: Fecal impaction is not the most common gastrointestinal complaint, as it is a condition that occurs when hardened stool accumulates in the rectum and cannot be expelled. Fecal impaction may cause abdominal pain, bloating, nausea, and loss of appetite. Fecal impaction is more common in older adults, people with low-fiber diets, or people who take certain medications, such as opioids or anticholinergics.

Choice B reason: Diarrhea is the most common gastrointestinal complaint, as it is a condition that occurs when the stool is loose, watery, and frequent. Diarrhea may cause dehydration, electrolyte imbalance, and malabsorption. Diarrhea can be caused by various factors, such as infections, food intolerance, medications, or irritable bowel syndrome.

Choice C reason: Constipation is not the most common gastrointestinal complaint, as it is a condition that occurs when the stool is hard, dry, and infrequent. Constipation may cause straining, pain, bleeding, and hemorrhoids. Constipation can be caused by various factors, such as lack of fluids, fiber, or exercise, or certain medications, such as antacids or iron supplements.

Choice D reason: Hemorrhoids are not the most common gastrointestinal complaint, as they are swollen veins in the lower rectum or anus that may cause itching, pain, or bleeding. Hemorrhoids can be caused by various factors, such as constipation, straining, pregnancy, or aging.

Choice E reason: None of the above is not the correct answer, as there is one choice that is the most common gastrointestinal complaint.

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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

Naxlex Comprehensive Predictor Exams

Which of the following assessment(s) is/are considered reliable in the older adult? (Select all that apply.)

Correct Answer is ["A","B"]

Explanation

What is the most common gastrointestinal complaint made to a health care provider?

Correct Answer is B

Explanation

When assessing your client who has a history of falls, you should pay particular attention to which of the following? (Select all that apply.)

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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?

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The nurse assists an older adult man who is diagnosed with type 2 diabetes mellitus to improve his glucose control. Which of the following instructions does the nurse give to this individual when he plans to walk more than usual in one day?

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