An older adult client complains of periods of confusion and forgetfulness, but reports clear thought process at most times of the day. Which is the appropriate response from the nurse?
A) "Are you having trouble hearing?"
B) "You probably have nothing to worry about. It's most likely stress-related."
C) "Everybody has a few problems with memory as they get older."
D) "You should probably have an MRI of your brain."
Answer: A
People who cannot hear or see well often appear confused. The nurse should assess whether the client is having difficulty with these prior to moving on in the assessment process. A nurse should never discount the client's concerns, and memory loss with confusion and forgetfulness is not part of the normal aging process. The nurse needs to explore further before an expensive diagnostic study is considered. It would be beyond the scope of practice for the nurse to recommend this testing.
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