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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Clozapine (Clozaril): Clozapine is an antipsychotic used primarily for schizophrenia, not for cognitive improvement in Alzheimer's disease. It is not indicated for treating Alzheimer’s disease.
B. Galantamine (Razadyne): Galantamine is an acetylcholinesterase inhibitor used to improve cognitive function in patients with mild to moderate Alzheimer's disease. It works by increasing the levels of acetylcholine in the brain, which helps with memory and cognitive processes.
C. Olanzapine (Zyprexa): Olanzapine is an antipsychotic used to treat schizophrenia and bipolar disorder. It is not used for cognitive enhancement in Alzheimer's disease and may actually worsen cognitive function in some cases.
D. Sertraline (Zoloft): Sertraline is an antidepressant used primarily for depression and anxiety disorders. It is not indicated for the cognitive symptoms of Alzheimer's disease.
Correct Answer is ["B","C","E"]
Explanation
A. Stand directly in front of the client when talking. Standing directly in front of a client with a history of anger and aggression can be perceived as confrontational and may escalate the situation. It's better to stand at an angle and maintain an open posture to appear less threatening. Therefore, this choice is incorrect.
B. Avoid wearing necklaces during client care. Wearing necklaces or other loose jewelry can pose a safety risk if a client becomes aggressive and grabs them. Avoiding such items is a precaution to prevent potential harm. This choice is correct.
C. Provide immediate verbal feedback for escalating behavior. Providing immediate verbal feedback is important to de-escalate aggressive behavior by addressing it promptly and setting clear boundaries. This helps in managing the client's behavior effectively. This choice is correct.
D. Bring security with you for all client interactions. While bringing security can be necessary in certain high-risk situations, it is not appropriate or practical for all interactions and can increase the client's anxiety or aggression. Instead, security should be involved based on risk assessment and the specific context. Therefore, this choice is incorrect.
E. Review the layout of the facility. Knowing the layout of the facility is important for ensuring safety and planning escape routes if a situation becomes unsafe. It helps staff navigate the environment efficiently in case of an emergency. This choice is correct.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
