While taking a history on an older adult male client, his wife reports that he is having increasing periods of short-term memory loss and he occasionally gets confused. How should the nurse proceed with an assessment of the client’s sensory system?

Choice A reason: While sensory status may be independent of cognition, the ability to participate in the assessment depends on the client’s capacity to understand and follow instructions. Proceeding without evaluating this may yield unreliable results. Choice B reason: Deferring the exam prematurely may result in missed opportunities to identify sensory deficits. A proper cognitive screening should guide whether the exam can be adapted or completed. Choice C reason: Assessing the client’s ability to follow directions ensures that the sensory exam will be meaningful and accurate. It allows the nurse to tailor the approach based on the client’s cognitive function. Choice D reason: Involving the wife in interpreting tests undermines the validity of the assessment and shifts responsibility away from the nurse. Sensory testing must be performed directly with the client.