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 A
Explanation
A. Dual diagnosis treatment: This group is appropriate as it addresses both the antisocial personality disorder and alcohol dependency. Dual diagnosis treatment provides integrated care for individuals with co-occurring mental health and substance use disorders, making it a suitable option for this client.
B. Codependency support: This group primarily focuses on individuals affected by another person's substance use or behavior rather than directly addressing the issues of substance dependence and personality disorders in the individual.
C. Psychodrama: While psychodrama can be useful for exploring interpersonal issues and emotional experiences, it may not specifically address the dual challenges of antisocial personality disorder and alcohol dependency as effectively as dual diagnosis treatment.
D. Crisis intervention: This group focuses on immediate problems and crisis management rather than ongoing management of complex, co-occurring disorders. It may not provide the comprehensive support needed for both antisocial personality disorder and alcohol dependency.
Correct Answer is D
Explanation
A. Involves respiratory therapy for altered breathing from severe anxiety levels: This behavior demonstrates collaboration with other healthcare professionals but does not directly relate to a team approach for managing mobility issues.
B. Delegates assessment of lung sounds to nursing assistive personnel: Delegation of tasks such as assessing lung sounds is a nursing responsibility but does not involve the broader team approach necessary for comprehensive care.
C. Becomes solely responsible for modifying activities of daily living: Handling all aspects of a patient's care individually does not reflect a team approach, which involves collaborating with various specialists.
D. Consults physical therapy for strengthening exercises in the extremities: This behavior exemplifies a team approach by involving physical therapy specialists to address mobility issues. It reflects collaboration with other disciplines to provide comprehensive care.
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