A nurse in an outpatient clinic is caring for a client.
Positron emission tomography (PET) scan of the head
Physical examination
Administer the Mini Mental State Examination (MMSE)
Review all prescribed and over-the-counter medications
Admit the client to an inpatient behavioral health unit
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}
Rationale for PET scan: A PET scan of the head is anticipated because the client is showing progressive cognitive decline, memory loss, and disorientation. Neuroimaging is appropriate to rule out structural or metabolic causes such as stroke, tumors, or neurodegenerative disease. This helps differentiate dementia from other neurological conditions.
Rationale for physical examination: A physical exam is anticipated because it provides a baseline assessment of the client’s overall health, identifies comorbid conditions, and evaluates neurological status. Physical findings can guide further diagnostic testing and management.
Rationale for MMSE: Administering the Mini Mental State Examination is anticipated because it is a standardized tool used to assess cognitive function, memory, orientation, and problem-solving ability. Given the client’s symptoms of forgetfulness, disorientation, and difficulty with daily tasks, the MMSE will help quantify cognitive impairment and track progression.
Rationale for medication review: Reviewing all prescribed and over-the-counter medications is anticipated because certain drugs can contribute to confusion, memory loss, or delirium. Polypharmacy and inappropriate medication use are common in older adults and can mimic or worsen dementia symptoms. Identifying and adjusting medications is a critical step in care.
Rationale for inpatient behavioral health admission: Admission to a behavioral health unit is not indicated at this stage. The client’s symptoms are consistent with progressive dementia rather than an acute psychiatric crisis. The focus should be on diagnostic evaluation, outpatient management, and support rather than psychiatric hospitalization
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Benztropine has anticholinergic properties, which decrease sweating rather than increase it. Clients are at risk for heat intolerance and hyperthermia, not diaphoresis.
Choice B reason:
Tachycardia is a common anticholinergic adverse effect due to vagal inhibition and increased heart rate. Monitoring cardiovascular status is essential, especially in older adults or those with cardiac disease.
Choice C reason:
Anticholinergic medications reduce gastrointestinal motility, leading to constipation rather than diarrhea. Therefore, diarrhea is not expected.
Choice D reason:
Benztropine causes urinary retention, not polyuria. Clients may have difficulty initiating urination or experience bladder distention.
Correct Answer is A
Explanation
Choice A reason: Informing the client that the admission is confidential is the first priority. Establishing trust and ensuring the client feels safe is essential before proceeding with further assessment or interventions. Confidentiality reassures the client that sensitive information will be protected, which is critical for someone who is fearful and withdrawn.
Choice B reason: Determining coping strategies is important but should occur after trust is established. A fearful client may not disclose coping mechanisms until they feel secure in the therapeutic relationship.
Choice C reason: Assisting the client in facilitating a change in behavior is premature during admission. The nurse must first assess and build rapport before initiating behavioral interventions.
Choice D reason: Introducing the client to others in the day room may increase anxiety. A fearful and withdrawn client may feel overwhelmed by social interaction before trust and safety are established.
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