When an older female adult client complains of itching and pain and several days later shows you a rash, what do you realize she has?

Choice A reason: This action is correct because the client is showing signs of a possible stroke, such as a severe headache and numbness in one side of the body. The nurse should call 9-11 immediately to get the client to the nearest hospital for urgent evaluation and treatment. The nurse should also monitor the client's vital signs, neurological status, and airway until help arrives.

Choice B reason: This action is incorrect because the client's headache and numbness are not likely to be caused by a migraine, but by a stroke. The nurse should not waste time asking about the client's history of headaches, but rather act quickly to get the client to the hospital. The nurse should also not assume that the client's symptoms are benign or familiar, but rather treat them as an emergency.

Choice C reason: This action is incorrect because the client's headache and numbness are not likely to be relieved by acetaminophen, but by a stroke. The nurse should not give the client any medication without a doctor's order, especially if the client has a history of TIA or stroke. The nurse should also not delay calling 9-11 by administering medication, as every minute counts in saving the client's brain cells.

Choice D reason: This action is incorrect because the client's headache and numbness are not likely to resolve within 24 hours, but by a stroke. The nurse should not reassure the client that the symptoms are temporary or harmless, but rather alert the client that they are signs of a serious condition. The nurse should also not delay calling 9-11 by providing false comfort, as the client's condition may worsen rapidly.

Choice A reason: Physical status is an important assessment for post-fall prevention, as it can identify the possible causes and consequences of the fall, such as injuries, pain, mobility, balance, strength, vision, hearing, cognition, and medication use. Physical status can also help determine the appropriate interventions and referrals for the older adult, such as physical therapy, occupational therapy, or home health care.

Choice B reason: Financial status is not an essential assessment for post-fall prevention, as it does not directly affect the risk or outcome of the fall. However, financial status may influence the older adult's access to health care, social support, and assistive devices, which may affect their recovery and quality of life. Financial status may also be a source of stress or anxiety for the older adult, which may impair their mental and emotional well-being.

Choice C reason: Occupational history is not an essential assessment for post-fall prevention, as it does not directly affect the risk or outcome of the fall. However, occupational history may provide some information about the older adult's past and current activities, skills, and interests, which may help tailor the interventions and goals for the older adult. Occupational history may also reflect the older adult's sense of identity, purpose, and satisfaction, which may affect their motivation and engagement.

Choice D reason: Environment is an important assessment for post-fall prevention, as it can identify the potential hazards and barriers that may contribute to the fall, such as poor lighting, slippery floors, clutter, loose rugs, stairs, or furniture. Environment can also help determine the appropriate modifications and adaptations that can reduce the risk of future falls, such as installing grab bars, handrails, ramps, or alarms. Environment can also influence the older adult's comfort, safety, and independence at home or in other settings.

Choice E reason: None of the above is not the correct answer, as there are two choices that are essential assessments for post-fall prevention.