The Nurse Is to Perform a Complete Assessment of a Patient

The nurse is to perform a complete assessment of a patient in her home,using the Mini-Mental State Examination (MMSE) as one component.When the nurse arrives,the patient is seated at the table with her husband,the TV is on,and several grandchildren are visiting.The patient is quiet,but her hands are gripped tightly,and she is staring at the ceiling.The best action for the nurse to take would be which of the following?

A) Ask the husband to make an appointment to bring his wife to the clinic for testing.
B) Explain to the husband that accurate data will be sought, and ask him to stay with the grandchildren in another room.
C) Do not perform the test during the assessment (because it will not be valid) and rely on observations and reports from the family.
D) Explain the importance of the testing process and make an appointment for another day when the environment can be better controlled.