A nurse is caring for an older adult client who has dementia and handles anxiety by confabulating. The nurse should recognize which of the following as confabulation?
A makes up stories when he is unable to remember actual events.
B reminisces about the past.
C displays compulsive and ritualistic behaviors.
D refuses to leave home to see a provider.
The Correct Answer is A
Choice A Rationale: A person who makes up stories when he is unable to remember actual events is confabulating. This can be seen as a way of filling in the blanks in their memory with plausible details that may or may not have happened. For example, a person with dementia may confabulate that they had lunch with a friend yesterday, when in fact they did not see anyone.
Choice B Rationale: reminiscing about the past, which is a normal and healthy way of recalling one's life experiences and sharing them with others.
Choice C Rationale: displaying compulsive and ritualistic behaviors, which are repetitive actions that a person feels compelled to perform, often as a way of reducing anxiety or distress.
Choice D Rationale: refusing to leave home to see a provider, which is a sign of agoraphobia, a fear of being in situations where escape might be difficult or embarrassing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Rationale: Notifying the nurse administrator should not be the first action when a client is experiencing pain or injury.
Choice B Rationale: Cleaning up the spill is important to prevent further accidents but does not address the client's immediate pain and discomfort.
Choice C Rationale: Asking the client to remain still is the best first action to ensure the client's safety and assess the extent of the injury or pain.
Choice D Rationale: Documenting the incident is important but should follow
Correct Answer is A
Explanation
Choice A Rationale: Assessing the client for bladder distention is the first and most crucial step in managing autonomic dysreflexia. Bladder distention is a common trigger for this condition in clients with spinal cord injuries. Identifying and addressing the cause (bladder distention) is the priority to prevent further complications.
Choice B Rationale: Laying the client flat may not resolve the underlying cause of autonomic dysreflexia and should be done after identifying and addressing the trigger.
Choice C Rationale: Obtaining the client's heart rate is important but should come after assessing for bladder distention since the primary concern in autonomic dysreflexia is elevated blood pressure due to a noxious stimulus.
Choice D Rationale: Administering a nitrate antihypertensive may be necessary if other interventions do not resolve the blood pressure elevation, but it should not be the first action. Identifying and addressing the cause, such as bladder distention, is the priority.
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