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: B

Rationale: The correct answer is B: radiation therapy. Radiation therapy uses high-energy radiation to target and destroy cancer cells while minimizing damage to surrounding healthy tissues. It is a localized treatment that is effective in shrinking tumors and preventing cancer cell growth. Surgery (A) involves physically removing the tumor and surrounding tissues, while chemotherapy (C) uses drugs to kill cancer cells throughout the body. Palliative treatment (D) focuses on symptom management and improving quality of life in advanced stages of cancer. In this case, the focus is on a form of cancer therapy involving high-energy electromagnetic radiation, making radiation therapy the most appropriate choice.

Correct Answer: A

Rationale: The correct answer is A because it is specific, measurable, achievable, relevant, and time-bound (SMART) - the patient verbalizing a decreased pain level less than 3 on a 0 to 10 scale by the end of this shift. This outcome is immediate, concrete, and directly related to the goal of managing pain. Choice B is incorrect as it lacks specificity and a clear timeframe for evaluation. Choice C is incorrect because the outcome is vague and does not specify when the patient needs to understand the dietary changes. Choice D is incorrect because the timeframe is provided but the outcome is not specific enough and does not directly relate to the goal of pain management.

Correct Answer: C

Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to directly gather data from the patient's body, such as vital signs, appearance, and overall health status. It provides essential information to establish a patient's database, including baseline values and potential health issues. Reviewing current literature (A) helps in decision-making but does not directly establish a patient's database. Checking orders for tests (B) and ordering medications (D) are part of the treatment process and do not focus on gathering initial patient data.

Correct Answer: C

Rationale: The correct answer is C: Diagnostic reasoning. Diagnostic reasoning involves using assessment data and critical thinking skills to develop a nursing diagnosis. This process includes analyzing and interpreting data to make clinical judgments about the patient's health status. A: Assigning clinical cues is incorrect because this refers to identifying and documenting specific observations or findings during the assessment process, not the process of developing a nursing diagnosis. B: Defining characteristics is incorrect because this refers to the specific symptoms or manifestations used to support a nursing diagnosis, not the overall process of diagnostic reasoning. D: Diagnostic labeling is incorrect because this refers to assigning a formal name to the nursing diagnosis, not the process of critically analyzing assessment data to develop it.

Correct Answer: C

Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to gather objective data directly from the patient's body, such as vital signs, skin condition, and overall health status. It provides a comprehensive overview of the patient's current health status and helps in establishing a baseline for further assessments and interventions. Reviewing literature (A) is important for evidence-based practice but does not directly establish a patient's database. Checking orders for tests (B) is essential but does not provide a holistic view of the patient. Ordering medications (D) is a treatment intervention and not a data collection method.

Correct Answer: C

Rationale: The correct answer is C: Performing a physical examination. This method allows the nurse to gather comprehensive data about the patient's health status, including vital signs, physical appearance, and potential health issues. It provides valuable information for developing an individualized care plan. Reviewing literature (A) is important but not for establishing a patient's database. Checking orders (B) and ordering medications (D) are part of the treatment process and do not directly contribute to establishing the initial patient database.

Correct Answer: C

Rationale: The correct answer is C: 5% dextrose in 0.9% NaCl. This solution is hypertonic because it has a higher osmolarity compared to the other choices. The presence of dextrose and NaCl in this solution increases its solute concentration, causing water to move out of the cells by osmosis. Normal saline (A) and 0.45% NaCl (B) are isotonic solutions, meaning they have the same osmolarity as body fluids. 0.225% NaCl (D) is a hypotonic solution with lower osmolarity than body fluids.

Correct Answer: B

Rationale: The correct answer is B because rifampin can cause discoloration of bodily fluids, including tears. If clients wear contact lenses, they need to be informed that the lenses may become colored due to this medication. This is important for the client's awareness and to prevent any potential harm to their eyes. A: Taking medication with meals is not necessary for rifampin administration. C: Avoiding wearing glasses is not relevant to rifampin treatment. D: Avoiding tuna, aged cheese, and red wine is not specifically related to rifampin use.