Question

the nurse is assessing a client who is unable to say where the client is or what year it is. which data should the nurse document that is most accurate?
a exhibits expressive dysphasia.
b demonstrates loss of remote memory.
c is disoriented to place and time.
d has a diminished attention span.

Explanation:

• Option A: Expressive dysphasia refers to difficulty producing speech, not inability to identify place/time.
• Option B: Remote memory is memory of distant past events, not current place/time awareness.
• Option C: Disorientation to place means not knowing one's location, and disorientation to time means not knowing the current year/time frame, which matches the client's symptoms.
• Option D: Diminished attention span involves difficulty focusing, not inability to identify place/time.

Answer:

C. Is disoriented to place and time.