A nurse is performing an admission assessment for a client who appears withdrawn and fearful. Which of the following actions should the nurse take first?

Choice A reason: Dissociation involves a disruption in consciousness, memory, identity, or perception of the environment. It is often seen when individuals detach from reality to avoid distressing emotions or experiences. In this case, the family member is not detaching from reality or experiencing a break in consciousness. Instead, they are expressing anger outwardly toward the provider. Therefore, dissociation does not apply.

Choice B reason: Rationalization is the use of logical-sounding explanations to justify or excuse unacceptable feelings or behaviors. For example, someone might say, “It was better this way” to justify a loss. The family member is not attempting to justify or excuse the death with reasoning; they are instead directing anger toward the provider. Thus, rationalization is not the defense mechanism being used.

Choice C reason: Repression is the unconscious blocking of unacceptable thoughts, feelings, or memories from awareness. It is a defense mechanism that prevents distressing emotions from surfacing. In this scenario, the family member is openly expressing anger and blame, not unconsciously suppressing emotions. Therefore, repression is not the correct mechanism.

Choice D reason: Displacement occurs when emotions are redirected from their original source to a safer or more acceptable target. The family member is experiencing grief and anger due to the parent’s death but is directing that anger toward the provider instead of confronting the painful reality of losing their parent. This redirection of emotions is a classic example of displacement, making it the correct answer.

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