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 client's main issue, which is the disturbance in their thought processes. The "related to" part (B) indicates the cause, "Alzheimer's disease" (C) is the etiology, and "incoherent language" (D) is the evidence. By focusing on the problem statement, the nurse can develop appropriate interventions to address the client's disturbed thought processes.

Correct Answer: A

Rationale: The correct answer is A: Ensure client safety. This is the nurse's primary legal responsibility as it aligns with the ethical principle of beneficence, prioritizing the well-being and safety of the client. Ensuring client safety is essential to prevent harm and promote positive health outcomes. Following physician orders precisely (B) is important but not the primary legal responsibility of the nurse. Documenting care comprehensively (C) is crucial for accountability and continuity of care but is not the primary legal responsibility. Providing client-centered education (D) is essential for empowering clients but is not the primary legal responsibility in terms of legal accountability and duty of care.

Correct Answer: B

Rationale: Correct Answer: B Rationale: Measuring intake and output and recommending increased fluid intake for a client with pyelonephritis is crucial to help flush out infectious microorganisms from the urinary tract. By increasing fluid intake, the client will urinate more frequently, aiding in the removal of bacteria causing the infection. This helps in reducing the bacterial load in the urinary tract and promoting faster recovery. Monitoring intake and output also helps ensure the client is adequately hydrated. Summary of Other Choices: A: Monitoring intake and output is more about assessing hydration status and kidney function rather than the response to therapy. C: Intake and output measurement does not directly determine the location of discomfort in pyelonephritis. D: Monitoring intake and output is not primarily for detecting changes but for ensuring proper fluid balance and aiding in infection clearance.

Correct Answer: B

Rationale: The correct answer is B: Drinking cranberry juice. Cranberry juice is known to help reduce urinary odor due to its acidic nature which can help eliminate bacteria that cause odor. It also helps to maintain urinary tract health. The other choices are incorrect because: A: Eating spicy foods can actually increase body odor and may not have any impact on urinary odor. C: Foods like eggs, asparagus, or cheese may contribute to strong body odor but do not specifically address urinary odor. D: Drinking tea, coffee, and colas can potentially worsen urinary odor due to their caffeine content and impact on urinary tract health.

Correct Answer: A

Rationale: The correct answer is A: Hypertension. In hypovolemia, the body compensates by increasing heart rate (B: Tachycardia) to maintain perfusion, decreasing urine output (C: Oliguria) to conserve fluid, and increasing respiratory rate (D: Tachypnea) to improve oxygenation. Hypertension is not a typical compensatory response to hypovolemia; instead, blood pressure tends to decrease due to reduced circulating volume. Therefore, hypertension is the symptom that would not be expected in a patient with hypovolemic shock.