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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Evaluate liver function: Although liver function tests can be important, they are not the immediate priority in anorexia nervosa unless there is a specific indication of liver disease or failure. Liver function abnormalities might occur in advanced cases due to malnutrition, but electrolyte imbalances are more immediately life-threatening.
B. Check for blood glucose levels: Blood glucose levels are important, but severe electrolyte imbalances, such as hypokalemia, pose a more immediate risk and require urgent attention to prevent cardiac and neurological complications.
C. Assess for signs of infection: While important, infection is not typically a primary concern in the initial assessment of someone with anorexia unless there are specific signs or symptoms indicating infection.
D. Monitor for electrolyte alterations: Electrolyte imbalances, such as hypokalemia (low potassium) and hypocalcemia (low calcium), can be life-threatening and are common in individuals with anorexia due to malnutrition, vomiting, or use of laxatives. These imbalances can lead to cardiac arrhythmias and other serious complications, making this the priority.
Correct Answer is B
Explanation
A. "Why did you feel you needed to do that at this time?": This response might come off as insensitive or judgmental. It could imply that the parents made an inappropriate decision without acknowledging their difficult situation.
B. "It must be frustrating for you to have to cancel an activity your son enjoyed.": This response validates the parents' feelings and acknowledges the emotional difficulty of making such a decision. It shows empathy and understanding of their situation.
C. "You never know. He could be ready for baseball by the spring.": This response offers false hope and may not be realistic given the child’s terminal illness. It could undermine the parents’ acceptance of the situation.
D. "Baseball can be a dangerous sport for children anyway.": This response dismisses the parents' feelings and does not acknowledge the real reason for canceling the activity. It is insensitive to the gravity of their situation.
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