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."

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. "Why did you feel you needed to do that at this time?": This response might come off as insensitive or judgmental. It could imply that the parents made an inappropriate decision without acknowledging their difficult situation.

B. "It must be frustrating for you to have to cancel an activity your son enjoyed.": This response validates the parents' feelings and acknowledges the emotional difficulty of making such a decision. It shows empathy and understanding of their situation.

C. "You never know. He could be ready for baseball by the spring.": This response offers false hope and may not be realistic given the child’s terminal illness. It could undermine the parents’ acceptance of the situation.

D. "Baseball can be a dangerous sport for children anyway.": This response dismisses the parents' feelings and does not acknowledge the real reason for canceling the activity. It is insensitive to the gravity of their situation.

A. Promoting social skills and communication development B. Administering medications to manage symptoms C. Implementing strict routines and schedules D. Providing sensory stimulation to reduce hyperactivity

Correct Answer is A

Explanation

A. Promoting social skills and communication development: This is a priority because individuals with Asperger's disorder often struggle with social interactions and communication. Interventions focus on improving these skills to enhance their quality of life and ability to function in society.

B. Administering medications to manage symptoms: While medications may be prescribed for co-occurring conditions (e.g., anxiety, ADHD), they are not typically the primary intervention for core symptoms of Asperger's disorder.

C. Implementing strict routines and schedules: Routine and structure can be beneficial for individuals with Asperger's disorder but are not the primary focus compared to social and communication skills.

D. Providing sensory stimulation to reduce hyperactivity: Sensory issues can be part of Asperger's disorder, but it is not the priority over social and communication development.

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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?

Nursing Test Bank

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Correct Answer is B

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Correct Answer is A

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