A nurse writes the following nursing diagnosis for a client with Alzheimer’s disease: 'Disturbed Thought Processes related to Alzheimer’s disease as evidenced by incoherent language.' Which part of this diagnosis is considered the problem statement?

Correct Answer: A

Rationale: The correct answer is A: Disturbed thought processes. This is the problem statement because it identifies the specific nursing diagnosis that reflects the client's cognitive impairment. "Disturbed thought processes" directly addresses the issue the nurse is observing in the client. The other choices are not the problem statement. "Related to" is the etiology or cause of the problem, "Alzheimer’s disease" is the medical condition, and "Incoherent language" is the defining characteristic or evidence of the problem. Therefore, A is the correct answer as it clearly states the client's primary issue.

Correct Answer: C

Rationale: During the evaluation phase, the nurse performs the key action of determining the effectiveness of the care plan. This involves assessing whether the client's goals are being met, if interventions are achieving the desired outcomes, and if any modifications are necessary. This step is crucial to ensure the care plan is successful and the client's needs are being addressed appropriately. Choice A is incorrect because diagnosing the client's condition is typically done in the assessment phase, not during evaluation. Choice B is incorrect as identifying nursing interventions is part of the planning phase. Choice D is incorrect as developing goals and outcomes is part of the planning phase as well. Overall, the evaluation phase focuses on assessing the effectiveness of the care plan rather than diagnosing, identifying interventions, or developing goals.

Correct Answer: D

Rationale: The correct action for the nurse to take is to notify the physician stat (choice D). Firstly, the patient presents with painful bladder spasms and blood-tinged urine, indicating a potential complication post-TURP. This warrants immediate medical attention to assess for possible bladder injury or hemorrhage. Giving Demerol (choice A) or B&O suppository (choice B) may provide symptomatic relief but does not address the underlying issue. Warming the irrigation solution (choice C) is not a priority in this situation and does not address the potential serious complications. Notifying the physician immediately allows for prompt evaluation and appropriate intervention to address the patient's condition effectively.

Correct Answer: B

Rationale: The correct answer is B: Human papillomavirus (HPV). HPV is the virus that causes genital warts. It is transmitted through sexual contact and is the most common sexually transmitted infection. Cytomegalovirus (A) does not cause genital warts. Herpes simplex virus type II (C) causes genital herpes, not warts. Human immunodeficiency virus (D) causes AIDS and weakens the immune system but does not directly cause genital warts.

Correct Answer: B

Rationale: The correct answer is B because administration of the diuretic furosemide without saline is not recommended for managing hypercalcemia. Furosemide can lead to volume depletion and potentially exacerbate hypercalcemia by concentrating calcium levels in the blood. A: Fluid administration helps dilute calcium levels by increasing urine output. C: Inorganic phosphate salts can bind with calcium in the gut, reducing absorption. D: Intravenous phosphate therapy can help lower calcium levels by promoting calcium-phosphate complex formation. In summary, B is incorrect as it may worsen hypercalcemia, while A, C, and D are valid strategies for managing hypercalcemia.