A nurse writes the following nursing diagnosis for a client with ...

[Beheh]

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?
 
  A) disturbed thought processes
  B) related to
  C) Alzheimer's disease
  D) incoherent language

Question 2

A nurse caring for an older adult client in a long-term care facility notices that the bedding is wet when the client gets up in the morning. The nurse collects more data to form a conclusion. What type of problem is involved in this scenario?
 
  A) No problem
  B) Possible problem
  C) Actual problem
  D) Clinical problem

[marict]

Answer to Question 1

Ans: A

The purpose of the problem statement is to describe the health state or health problem of the client as clearly and concisely as possible. Because this section of the nursing diagnosis identifies what is unhealthy about the client and what the client would like to change in his or her health status, it suggests client outcomes. NANDA recommends the use of quantifiers or descriptors to limit or specify the meaning of a problem statement. Disturbed thought processes is a NANDA-approved descriptor for this client problem. The etiology identifies the physiologic, psychological, sociologic, spiritual, and environmental factors believed to be related to the problem as either a cause or a contributing factor, and in this case is Alzheimer's disease. Incoherent language is considered a defining characteristic or subjective/objective data signaling the existence of an actual or potential health problem.

Answer to Question 2

Ans: B

The nurse reaches one of four basic conclusions after interpreting and analyzing the client data: no problem, possible problem, actual or potential problem, or clinical problem. When dealing with a possible problem, the nurse must collect more data to confirm or disprove a suspected problem.

[Beheh]

Excellent

[aruss1303]

TYSM