A nurse in an outpatient clinic is caring for a client.

 

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

Choice A reason: While this statement is true, it is confrontational and does not address the nurse’s legal and professional responsibility. Nurses must prioritize child safety and follow mandated reporting laws rather than offering judgmental statements.

Choice B reason: Asking the parent why they think it will not happen again is inappropriate. It places responsibility on the parent and may minimize the seriousness of the abuse. The nurse’s role is to protect the child, not to debate with the caregiver.

Choice C reason: Reporting suspected child abuse is not optional or left to the parent. It is a legal obligation of healthcare providers. Suggesting that it is the parent’s responsibility misrepresents the nurse’s duty and could result in failure to protect the child.

Choice D reason: Informing the parent that the child will be privately interviewed is appropriate. This ensures the child’s voice is heard without parental influence and allows professionals to assess the situation accurately. It also communicates the seriousness of the incident while maintaining professionalism