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
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Placing a soft rug in front of the client’s chair increases the risk of tripping and falling. Clients with dementia often have impaired judgment, coordination, and gait instability. Loose rugs are a well-known environmental hazard in home safety assessments, and therefore this intervention is unsafe.
Choice B reason: Setting the water heater at 140° F is dangerous because clients with dementia may not recognize the risk of burns. Safe water heater settings are typically recommended at or below 120° F to prevent scalding injuries. High temperatures pose a significant safety risk for cognitively impaired individuals.
Choice C reason: Encouraging a 1-hour nap in the afternoon is beneficial. Clients with dementia often experience fatigue, irritability, and sundowning (worsening confusion in the evening). A structured rest period helps reduce agitation, improves mood, and supports overall functioning. This intervention promotes both safety and comfort.
Choice D reason: Limiting fluid intake after the evening meal can lead to dehydration and urinary tract infections. While nighttime incontinence may be a concern, restricting fluids is not recommended because hydration is critical for cognitive and physical health. Instead, toileting schedules and protective measures should be used.
Correct Answer is D
Explanation
Choice A reason: Sleeping only 4 hours is common during mania and contributes to exhaustion, but it is not immediately life-threatening.
Choice B reason: Refusing to shower reflects poor self-care, which is expected in mania, but it does not pose an acute medical risk.
Choice C reason: Eating half a snack shows reduced intake but is not as urgent as fluid refusal.
Choice D reason: Refusing fluids is the priority because dehydration can quickly lead to severe complications such as electrolyte imbalance, cardiac dysrhythmias, and renal impairment. This requires immediate intervention.
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