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."
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Related Questions
Correct Answer is B
Explanation
A. Review the steps for checking a radial pulse with the client: This method involves cognitive learning, as it focuses on understanding and recalling information rather than performing a physical skill.
B. Observe the client checking their radial pulse: This method involves the psychomotor domain because it focuses on the client's ability to perform the physical task of checking their pulse. The nurse can assess the client’s skill in action.
C. Tell the client the expected reference range of their radial pulse: This approach falls under cognitive learning, focusing on providing factual information rather than hands-on practice.
D. Discuss the purpose of checking the radial pulse with the client: This is also a cognitive learning method, as it involves understanding the reasons behind the procedure rather than the physical execution of it.
Correct Answer is B
Explanation
A. The goal of palliative care is to prolong the life of a client: The primary goal of palliative care is to improve the quality of life by managing symptoms and providing comfort, rather than focusing solely on prolonging life.
B. Palliative care is not restricted to clients who are terminally ill: Palliative care can be provided to clients at any stage of a serious illness, regardless of whether they are terminally ill. It focuses on relief from symptoms and improving quality of life.
C. Palliative care should be avoided for a client who is receiving a cure: Palliative care can be provided alongside curative treatment to manage symptoms and improve quality of life throughout the treatment process.
D. Palliative care is limited to clients who are in a healthcare facility: Palliative care can be provided in various settings, including home care, outpatient clinics, and healthcare facilities.
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