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.
Nurse examining and measuring hematuria sample from client with a UTI
Peptic ulcer disease (PUD).
Client and therapist positioning for foot reflexology.
Measuring the client’s height with a platform scale
Nursing: A Concept-Based Approach to Learning, Volume I
Nursing: A Concept-Based Approach to Learning, Volume II, 3rd Edition