The nurse identified that the patient has pain of 7 on a scale of 1 to 10 and he expresses discomfort over the incisional area. He guards the area by resisting movement. Which component is the S in a three-part nursing diagnostic statement using the PES format? Nursing Diagnosis: Acute pain r/t incisional trauma with guarding and restricted movement
Acute Pain
Natural swelling
Guarding and restricted movement
Related to incisional trauma
The Correct Answer is C
A. Acute Pain: This represents the diagnostic label in the nursing diagnosis but does not include specific symptoms or evidence related to the client's condition.
B. Natural swelling: This is not relevant to the symptoms described in the scenario and does not represent the specific signs of the client's condition.
C. Guarding and restricted movement: This describes the specific observable signs and symptoms reported by the patient, which are part of the "Signs and Symptoms" component (S) in the PES format.
D. Related to incisional trauma: This part of the diagnosis describes the cause or contributing factor of the pain, which is the "Etiology" component, not the "Signs and Symptoms."
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "The medication may cause ringing in my ears.": Ringing in the ears (tinnitus) is not a common side effect of haloperidol. This statement does not indicate understanding of the medication’s typical side effects.
B. "The medication may cause urinary incontinence.": Urinary incontinence is not a common side effect of haloperidol. This statement is not accurate regarding the medication's effects.
C. "I may be more sensitive to the sun while taking this medication.": This statement indicates understanding, as haloperidol can increase sensitivity to sunlight, making clients more susceptible to sunburn.
D. "I may experience a metallic taste while taking this medication.": A metallic taste is not a common side effect of haloperidol. This statement does not reflect the typical effects of the medication.
Correct Answer is A
Explanation
A. Provide educational material written at an eighth-grade reading level: This ensures that the educational material is accessible and understandable for clients, facilitating better comprehension and retention of information.
B. Turn on the television in the client's room: This is not conducive to effective teaching and may distract the client from the important information being provided.
C. Use technical language in the educational session: Using technical language can confuse clients and hinder their understanding. It is better to use plain language to ensure clarity.
D. Start with the most important information: While prioritizing information is important, the initial focus should be on assessing the client's understanding and tailoring the teaching to their specific needs before covering critical details.
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