A nurse in an acute care facility is assessing a client who had hip surgery and has Alzheimer's disease. The nurse asks the client how therapy went that morning. Which of the following statements by the client should the nurse document as confabulation?

"I just don't remember what I did this morning."

"This morning, this morning, this morning..."

"It was good. The Queen of England visited me there."

"Snip, snap. Take a nap."

Answer and Explanation

The Correct Answer is C

A. "I just don't remember what I did this morning." This statement reflects an inability to recall the events of the morning, which is a common symptom in Alzheimer's disease but does not constitute confabulation. It simply indicates memory loss.

B. "This morning, this morning, this morning..." Repetition of words or phrases can indicate a language or communication issue often seen in Alzheimer's disease but is not an example of confabulation. It may reflect confusion or perseverance.

C. "It was good. The Queen of England visited me there." Confabulation involves the creation of false memories or statements to fill in gaps in memory. The client's statement about the Queen of England visiting is a fabricated or distorted memory and is an example of confabulation. This choice is correct.

D. "Snip, snap. Take a nap." This phrase is nonsensical and may indicate disorganized thinking or speech, which can occur in Alzheimer's disease, but it is not an example of confabulation. It does not fill a memory gap with a fabricated story. Therefore, this choice is incorrect.

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Correct Answer is A

Explanation

A. Promoting social skills and communication development: This is a priority because individuals with Asperger's disorder often struggle with social interactions and communication. Interventions focus on improving these skills to enhance their quality of life and ability to function in society.

B. Administering medications to manage symptoms: While medications may be prescribed for co-occurring conditions (e.g., anxiety, ADHD), they are not typically the primary intervention for core symptoms of Asperger's disorder.

C. Implementing strict routines and schedules: Routine and structure can be beneficial for individuals with Asperger's disorder but are not the primary focus compared to social and communication skills.

D. Providing sensory stimulation to reduce hyperactivity: Sensory issues can be part of Asperger's disorder, but it is not the priority over social and communication development.

A. Permanent short-term memory loss B. Nasal septum perforation C. Acute pancreatitis D. Respiratory depression/arrest

Correct Answer is D

Explanation

A. Permanent short-term memory loss: While certain substances, particularly chronic alcohol use, can lead to memory impairment, permanent short-term memory loss is not a typical complication of heroin use. Heroin primarily affects the respiratory system and can lead to other health risks such as overdose and infection. Therefore, this choice is incorrect.

B. Nasal septum perforation: Nasal septum perforation is typically associated with the intranasal use of substances like cocaine, which can damage the nasal tissues. Heroin is more commonly injected or smoked, and nasal perforation is not a primary health risk associated with its use. Therefore, this choice is incorrect.

C. Acute pancreatitis: Acute pancreatitis is commonly associated with excessive alcohol consumption rather than heroin use. Heroin primarily affects the central nervous and respiratory systems rather than the pancreas. Therefore, this choice is incorrect.

D. Respiratory depression/arrest: Heroin use poses a significant risk of respiratory depression and arrest, which can be fatal. It depresses the central nervous system and slows down breathing, potentially leading to severe hypoxia and death, especially in the case of overdose. This choice is correct.

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A nurse in an acute care facility is assessing a client who had hip surgery and has Alzheimer's disease. The nurse asks the client how therapy went that morning. Which of the following statements by the client should the nurse document as confabulation?

Nursing Test Bank

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