Which nursing documentation entry accurately describes a client's use of confabulation?
"Attempts to communicate by using rhyming words."
"Nonverbals indicate communication with unseen others."
"Verbalizes happiness about trip to park which was not based in fact."
"Rambles about early childhood experiences jumping from topic to topic."
The Correct Answer is C
Confabulation involves the fabrication of details or events to fill in gaps in memory. In this case, the client is expressing happiness about a trip to the park that did not actually occur, which is an example of confabulation.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
A) Incorrect. While understanding the reasons behind the suicidal thoughts is important, in this immediate situation, assessing access to means (medications) is crucial.
B) Correct. This question assesses the immediate risk by determining if the friend has access to the means (medications) to carry out the overdose.
C) Incorrect. While substance use is a risk factor, it may not directly address the immediate threat of overdose with pills.
D) Incorrect. While family issues can contribute to emotional distress, the most pressing concern is the immediate risk of overdose.
Correct Answer is C
Explanation
A. This response does not directly address the client's concern and may be perceived as dismissive.
B. This response does not provide a clear explanation for the locked door and may not effectively address the client's agitation.
C. This response provides a clear and honest explanation for the locked door, ensuring the client's safety, which is the priority.
D. This response acknowledges the situation but does not provide a clear explanation for the locked door.
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