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 D

Explanation

A. Reprimand the client about the potential damage that has occurred due to overexercising her body. Reprimanding the client is not therapeutic and can increase feelings of guilt or shame, potentially exacerbating the condition. A more supportive and understanding approach is needed to address the behavior. Therefore, this choice is incorrect.

B. Praise the client for looking at herself in a mirror. Praising the client for looking at herself in the mirror is not specifically relevant to managing the overexerting behavior and does not address the core issues of anorexia nervosa. It may also reinforce body image concerns. Therefore, this choice is incorrect.

C. Restrict the client from being weighed. Weighing restrictions are common in the treatment of anorexia nervosa to reduce anxiety around weight gain. However, this action alone does not directly address the overexercising behavior. Instead, comprehensive behavioral and therapeutic strategies should be employed. Therefore, this choice is incorrect.

D. Ask the client to agree to talk to a nurse whenever she feels the urge to exercise. Encouraging the client to discuss her urges to exercise with a nurse provides an opportunity for therapeutic intervention and support. It helps in addressing the behavior in a constructive manner and provides a means for the client to seek help when struggling with their impulses. This choice is correct.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

The adolescent is at greatest risk for: i. Impaired social interaction as evidenced by the adolescent's ii. discourteous behavior.

Rationale: The adolescent's behavior, such as sneaking out, roaming the neighborhood alone, and not following teachers' directions, indicates difficulties in interacting appropriately within social contexts and respecting boundaries, which can lead to impaired social interactions.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client diagnosed with anorexia nervosa and overexercises to avoid gaining weight. Which of the following should be the appropriate action by the nurse?

Correct Answer is D

Explanation

A nurse in a clinic is caring for an adolescent. Exhibits Complete the following sentence by using the lists of options. The adolescent is at greatest risk for dropdown as evidenced by the adolescent's dropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

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