Correct Answer: C

Rationale: The correct answer is C: Abdominal girth. Serum albumin helps to increase oncotic pressure in the blood vessels, reducing fluid leakage into the abdomen and decreasing ascites, leading to a decrease in abdominal girth. Option A is incorrect because serum albumin does not directly affect urinary output. Option B is incorrect as serum albumin does not directly impact serum ammonia levels. Option D is incorrect because while serum albumin can help improve liver function, it does not directly treat hepatic encephalopathy.

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: B

Rationale: The correct answer is B: "I will press the button whenever I feel pain." This answer demonstrates understanding of how patient-controlled analgesia (PCA) works, where the client self-administers medication when needed for pain relief. Option A is incorrect as the machine is programmed with lockout intervals to prevent overdosing. Option C is incorrect as the client should only press the button when experiencing pain, not on a fixed schedule. Option D is incorrect as PCA does not guarantee complete pain elimination. The key in PCA is empowering the client to self-administer medication based on their pain level.

Correct Answer: C

Rationale: The correct answer is C: Clinical pathways. Clinical pathways are standardized, evidence-based interdisciplinary plans of care used in case management to guide the treatment and management of clients. They outline the expected course of treatment, interventions, and outcomes for specific health conditions. Kardex care plans (A) are outdated paper-based patient information systems, not specifically for interdisciplinary care plans. Computerized plans of care (B) may refer to electronic health records but do not necessarily imply standardized interdisciplinary plans. Student care plans (D) are educational tools for students and not typically used in case management for clients.

Correct Answer: B

Rationale: The correct answer is B because turning the patient every 2 hours helps prevent pressure ulcers caused by shearing forces. This intervention redistributes pressure, improving blood flow to the skin, thus reducing the risk of skin breakdown. Administering pain medication (A) does not directly address the skin integrity issue. Monitoring vital signs (C) is important but does not address skin integrity. Keeping bed rails up (D) may actually increase the risk of shearing forces.