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 B
Explanation
Choice A Rationale: Using antipsychotics around the clock is not an appropriate approach for managing Alzheimer's disease and may have adverse effects.
Choice B Rationale: "She will not be left home alone" indicates effective teaching because it emphasizes the importance of supervision and safety for a client with Alzheimer's who may be at risk of wandering or accidents.
Choice C Rationale: Applying a restraint to only one wrist is not an appropriate or effective strategy for managing Alzheimer's-related behaviors and may have ethical concerns.
Choice D Rationale: Placing rugs in the bathroom may create tripping hazards for a client with Alzheimer's. Effective teaching should focus on removing hazards rather than adding them.
Correct Answer is D
Explanation
Choice A Rationale: Guillain-Barre syndrome does not typically cause enlargement of parotid and salivary glands, leading to drooling.
Choice B Rationale: Obstructed blood flow to the brain is not the primary cause of the described symptoms in Guillain-Barre syndrome.
Choice C Rationale: Deficiency of thiamine and pyridoxine in the central nervous system is not a characteristic feature of Guillain-Barre syndrome.
Choice D Rationale: In Guillain-Barre syndrome, demyelination affects cranial nerves responsible for swallowing and the gag reflex, leading to difficulties in swallowing secretions and drooling.
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