An elderly client, who has fallen several times at home, is admitted for possible transient ischemic attack (TIA). Which assessment finding is most significant in determining care for this client?
A) Becomes confused during the night
B) Drooling from side of mouth
C) Bruit heard over carotids
D) Irregular heart rhythm
B
Feedback:
Facial droop and drooling from the side of the mouth can indicate progression of symptoms or evolving CVA. It is not unusual for elderly clients to become confused when placed in a new environment and would indicate a need for further assessment. Bruits over the carotids may indicate altered blood flow to the brain but may not be a new finding for this client. Irregular heart rate can be indicative of atrial fibrillation or other cardiac disorders.
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