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?

Choice A reason: Over-the-counter NSAIDs are generally harmless is not a true statement, as NSAIDs can cause serious adverse effects in older adults, such as gastrointestinal bleeding, renal impairment, hypertension, and heart failure. NSAIDs should be used with caution and under medical supervision in older adults.

Choice B reason: Stool softeners and laxatives should be used with opioids is a true statement, as opioids can cause constipation in older adults, which can lead to discomfort, abdominal pain, fecal impaction, and bowel obstruction. Stool softeners and laxatives can help prevent and treat constipation and promote regular bowel movements.

Choice C reason: Opioids are less effective in older clients than in younger clients is not a true statement, as opioids can have the same or even greater analgesic effect in older adults, depending on the dose, route, and duration of administration. However, opioids can also cause more side effects in older adults, such as sedation, confusion, respiratory depression, and falls. Opioids should be used with caution and under medical supervision in older adults.

Choice D reason: The dose limit for acetaminophen is difficult to reach for older adults is not a true statement, as older adults may be more susceptible to acetaminophen toxicity, especially if they have liver disease, malnutrition, or chronic alcohol use. The dose limit for acetaminophen is 4 grams per day for adults, but it may be lower for older adults or those with risk factors. Acetaminophen should be used with caution and under medical supervision in older adults.

Choice A reason: Grab bars in place are important for preventing falls, as they provide support and stability for the patient when moving around the room, especially in the bathroom. Grab bars can help the patient maintain their balance and avoid slipping or tripping.

Choice B reason: Appropriate footwear is important for preventing falls, as it can reduce the risk of slipping, sliding, or stumbling. Appropriate footwear should fit well, have non-skid soles, and be comfortable and easy to put on and take off.

Choice C reason: Outdoor grounds are not a factor in the patient care environment that should be routinely assessed to decrease the risk of falls, as they are not part of the indoor setting where most falls occur. However, outdoor grounds may pose a fall hazard for patients who go outside for recreation or therapy, and should be checked for uneven surfaces, obstacles, or slippery conditions.

Choice D reason: All four bed rails raised are not a factor in the patient care environment that should be routinely assessed to decrease the risk of falls, as they may actually increase the risk of falls and injuries. Bed rails may create a false sense of security, encourage the patient to climb over them, or entrap the patient between the rails and the mattress. Bed rails should be used only when indicated and with the patient's consent.

Choice E reason: None of the above is not the correct answer, as there are two factors in the patient care environment that should be routinely assessed to decrease the risk of falls.