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

A. The client will teach back information about safe crutch walking on day 1: This goal includes a specific time frame ("on day 1") which makes it a timed component. It establishes when the client is expected to demonstrate understanding, aligning with the SMART criteria for setting time-specific goals.

B. The client will demonstrate safe crutch walking: While this goal describes a desired outcome, it does not include a time frame, so it lacks the timing component needed for SMART criteria.

C. The client will not lean on the crutches to support their body weight: This goal focuses on the behavior change but does not specify when this should be achieved, missing the timed element of SMART goals.

D. The client will ambulate 5 feet in one day: This goal has a specific time frame ("in one day"), indicating when the client should achieve the goal, which is a critical aspect of SMART outcomes.

E. The client will walk 10 feet by day 2: This goal includes a specific time frame ("by day 2"), providing a clear deadline for achieving the goal, which is essential for SMART objectives.

F. The client will walk 20 feet by day 3: This goal includes a specific time frame ("by day 3"), which provides a deadline for reaching the goal, meeting the criteria for SMART goals.

G. The client will explain 4 principles of crutch safety: This goal describes an outcome but does not include a time frame, so it lacks the timed aspect necessary for SMART goals.

H. The client will explain how to keep crutches in safe condition: This goal focuses on an outcome without specifying a deadline, thus missing the timed component required for SMART goal setting.

A. Anemia: While stress can have various effects on the body, anemia is not specifically a direct manifestation of prolonged stress. It is more commonly associated with nutritional deficiencies or chronic disease.
B. Hypoglycemia: Prolonged stress typically leads to increased levels of cortisol and other stress hormones, which can cause hyperglycemia (elevated blood sugar) rather than hypoglycemia (low blood sugar).
C. Decreased blood pressure: Prolonged stress usually causes increased blood pressure rather than decreased blood pressure. The body's stress response involves the release of hormones that typically raise blood pressure.
D. Impaired immune function: Prolonged stress can lead to immune system suppression, making the body more susceptible to infections and illnesses. This is a well-documented effect of chronic stress and is thus a correct manifestation to include in the teaching.