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?
A.
Call 9-1-1.
B.
Determine if the client has a history of migraine headaches.
C.
Give the client a dose of acetaminophen.
D.
Assure the client the symptoms will resolve within 24 hours.
E.
None of the above.
In this situation, the client’s symptoms—severe headache and numbness in the left arm—are concerning because they may indicate a possible stroke or worsening of the TIA. The initial action should prioritize the client’s immediate safety and address the potential for a more serious condition.
Correct Action:
A. Call 9-1-1.
Explanation:
- Severe Headache and Numbness in the Left Arm:
- These symptoms, especially after a recent TIA, could indicate the onset of a full-blown stroke. The client needs immediate medical evaluation to determine the cause and receive appropriate treatment.
- Rationale for Other Options:
- B. Determine if the client has a history of migraine headaches: While a history of migraines might provide context, it does not address the immediate concern of potentially acute symptoms.
- C. Give the client a dose of acetaminophen: This does not address the possibility of a serious condition such as a stroke and may delay necessary emergency intervention.
- D. Assure the client the symptoms will resolve within 24 hours: This is inappropriate given the severity of the symptoms and the risk of a stroke.
Calling 9-1-1 ensures that the client receives prompt medical attention, which is critical in cases involving potential strokes or significant changes in neurological status.