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 D

Explanation

A. "Lab work is only needed at the start of taking the medication." This statement is incorrect. Regular monitoring of lithium levels and kidney function through lab work is crucial for ensuring the medication's effectiveness and preventing potential toxicity.

B. "Once I feel better, I will not need to take this medication anymore." This statement is incorrect. Lithium is typically prescribed for long-term maintenance in bipolar disorder to prevent relapses and stabilize mood.

C. "There is a chance I may become addicted to this medication." This statement is incorrect. Lithium is not addictive. It is a mood stabilizer used to manage bipolar disorder.

D. "I need to be aware of situations that may cause dehydration." This statement demonstrates an understanding of an important consideration with lithium. Dehydration can lead to an increase in lithium levels in the body, potentially leading to toxicity. It's important for clients taking lithium to stay well hydrated and be cautious in situations that may lead to dehydration.

A. A depressant B. An opioid C. A stimulant D. An inhalant

Correct Answer is C

Explanation

A. A depressant Depressants typically slow down the central nervous system, leading to
symptoms like sedation, slowed heart rate, and reduced blood pressure. The symptoms described in the question, such as tachycardia, hypertension, restlessness, and agitation, are not
characteristic of depressant use.

B. An opioid Opioids primarily lead to central nervous system depression, resulting in symptoms like respiratory depression, sedation, and decreased heart rate. The symptoms described in the question, such as tachycardia and restlessness, are not typical of opioid use.

C. A stimulant Stimulants, such as amphetamines or cocaine, lead to increased activity in the central nervous system, resulting in symptoms like tachycardia, hypertension, restlessness, and agitation. These symptoms align with the presentation described in the question.

D. An inhalant Inhalants can lead to a variety of effects, including dizziness, confusion, and sometimes increased heart rate. However, they are not typically associated with the specific symptoms of tachycardia, hypertension, restlessness, and agitation described in the question.

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

Correct Answer is D

Explanation

A client is admitted with tachycardia, hypertension, restlessness, agitation, and admits substance use. Which substance would be most likely to cause these symptoms?

Correct Answer is C

Explanation

The nurse is admitting a client with a dual diagnosis of major depressive disorder and alcohol abuse. What is the primary intervention?

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