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

Answer and Explanation

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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Correct Answer is A

Explanation

A. Clean hands with soap and water after caring for the client: C. difficile spores are resistant to alcohol-based hand sanitizers. Therefore, it is essential to use soap and water to effectively remove the spores from hands.
B. Place the client in a room with negative pressure airflow: C. difficile is not an airborne infection, so negative pressure airflow is not required. This measure is typically used for infections such as tuberculosis.
C. Wash hands for 10 seconds after caring for the client: Handwashing with soap and water should be done for at least 20 seconds to effectively remove C. difficile spores.
D. Apply a mask on the client when they are outside their room: A mask is not necessary for clients with C. difficile, as the infection is not transmitted through respiratory droplets but rather through fecal-oral transmission.

A. Bronchial airway constriction B. Hypoglycemia C. Dilated pupils D. Decreased blood pressure

Correct Answer is C

Explanation

A. Bronchial airway constriction: In the fight-or-flight response, bronchial airways actually dilate to increase airflow to the lungs, rather than constricting.
B. Hypoglycemia: The fight-or-flight response typically leads to increased blood glucose levels (hyperglycemia) to provide quick energy, not decreased levels.
C. Dilated pupils: During the fight-or-flight response, pupils dilate to improve vision and help the individual better detect threats. This is a classic manifestation of this stress response.
D. Decreased blood pressure: The fight-or-flight response generally increases blood pressure due to the release of adrenaline and other stress hormones that prepare the body for immediate action.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

nurse is caring for a client who has Clostridium difficile (C. difficile). Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is teaching a class about physical manifestations associated with the fight-or-flight response to stress. Which of the following manifestations should the nurse include?

Correct Answer is C

Explanation

The nurse is reviewing interventions written for a client. Which of the following should the nurse consider as being independent?

A nurse is teaching a client about using a cane for ambulation. Which of the following statements should the nurse make?

The nurse working in the ER is admitting a toddler to the orthopedic unit. The parents and grandparents are at bedside. What should the nurse use as the best source of data for this client?

A nurse is teaching a class about physical manifestations associated with the fight-or-flight response to stress. Which of the following manifestations should the nurse include?

A nurse obtained a telephone order from a primary care provider for a patient in pain. Which chart entry should the nurse document?

A nurse is preparing to transfer a client who has left-sided weakness from a sitting position in bed to a chair. Which of the following actions should the nurse take?

A nurse is planning to perform perineal care for a female client. Which of the following actions should the nurse plan to take?