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 A
Explanation
Choice A Rationale: "You sound overwhelmed, can you tell me more?" is an empathetic response that encourages the caregiver to express their feelings and concerns. It opens the door for effective communication and understanding.
Choice B Rationale: "It will take time, but lots of people do it" may be true, but it does not directly address the caregiver's emotional state or offer support.
Choice C Rationale: "What do you think will be the hardest thing to handle?" is a probing question that can help identify specific concerns, but it may not be the most appropriate initial response.
Choice D Rationale: "The entire healthcare team will manage most of the disease process" does not acknowledge the caregiver's emotions and concerns and may not provide the needed support.
Correct Answer is C
Explanation
Choice A Rationale: Applying a vest restraint should not be the first action and should only be considered as a last resort after other alternatives have been explored.
Choice B Rationale: Placing the client in bed with two side rails raised may restrict the client's mobility and is not the first choice for managing agitation.
Choice C Rationale: Placing a seat alarm in the client's chair is the first action to take because it allows the nurse to monitor the client's movements and respond promptly to any attempts to get out of the chair while ensuring safety.
Choice D Rationale: Administering lorazepam should not be the first action and should only be considered after non-pharmacological interventions have been attempted
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