The nurse is preparing to administer a Mini-Mental Status Examination (MMSE) on a 75-year-old client admitted for clinical depression. The nurse's initial intervention for this specific client is to:
1. Plan for the test when the client will not to be rushed to complete it.
2. Repeat the instructions just prior to beginning the assessment.
3. Arrange for the client to be uninterrupted during the test.
4. Make sure the client is not hungry or in pain when taking the test.
Plan for the test when the client will not to be rushed to complete it.
Rationale: Planning for the test when the client will not to be rushed to complete it is particularly important for the elderly client due to decreased processing speed; allow adequate time for the older client to respond to the examination items. Repeating the instructions, arranging for the client to be uninterrupted, and addressing hunger and pain issues are interventions that are appropriate for any client regardless of age.
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