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."

Answer and Explanation

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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Correct Answer is B

Explanation

A. Wernicke encephalopathy is caused by thiamine (Vitamin B1) deficiency, but it is not characterized by thiamine deficiency itself.
B. Wernicke encephalopathy is characterized by lesions in the hypothalamus and mammillary bodies in the brain.
C. While cognitive impairment may be present, this is not the primary characteristic of Wernicke encephalopathy.
D. Double vision and rapid eye movement are symptoms of Wernicke encephalopathy, but they are not the irreversible complication itself.

A. The client has increasing aggression. B. The client has elevated blood pressure. C. The client has complaints of dizziness. D. The client has extrapyramidal symptoms (EPS).

Correct Answer is D

Explanation

A. Increasing aggression may be an indication for a PRN medication, but benztropine specifically targets extrapyramidal symptoms (EPS).
B. Elevated blood pressure is not a direct indication for benztropine; it is used to address EPS.

C. Complaints of dizziness may not be directly related to EPS, which is the target of benztropine.
D. Benztropine is an anticholinergic medication used to manage extrapyramidal symptoms (EPS) associated with antipsychotic medications like haloperidol.

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Which nursing documentation entry accurately describes a client's use of confabulation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with chronic alcoholism has been found to have Wernicke encephalopathy. What is this irreversible complication characterized by?

Correct Answer is B

Explanation

Benztropine is ordered as needed (PRN) for a client taking haloperidol after being diagnosed with schizoaffective disorder. Which of the following assessments by the nurse would indicate a need for this medication?

Correct Answer is D

Explanation

The mother of a 20yearold woman recently diagnosed with paranoid schizophrenia asks the nurse what causes schizophrenia. The nurse recognizes which of the following are implicated in the etiology of schizophrenia?

Which statement provides the best rationale for why a nurse should closely monitor a severely depressed client during antidepressant therapy?

An 80 year-old client, together with his daughter, arrived at the medical surgical unit for diagnostic confirmation and management of probable delirium. Which statement by the client's daughter best supports the diagnosis?

What intervention is a priority when the client is experiencing auditory hallucinations?

A nurse is preparing to administer fluoxetine 80 mg PO daily. Available is fluoxetine 40 mg/5mL. How many mL should the nurse administer per dose? (Write the number only, do not include the label. Record the answer to the nearest whole number. Do not use a trailing zero)

A client has been prescribed lithium for long-term maintenance of bipolar disorder diagnosis. Which statement by the client shows an understanding of the medication?

While caring for a depressed client, a nurse would evaluate the need for suicide precautions under which circumstance?

A physician has prescribed an antidepressant medication for a 15yearold client. Which statement would be appropriate for inclusion in medication teaching?