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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Grandparents: While grandparents can provide useful information, the primary and most accurate data source for a toddler's immediate care and developmental history would typically be the parents, who are the primary caregivers.
B. Admitting provider: The admitting provider offers valuable medical information, but the best source of data regarding the child’s current condition and history would come from those who are closest to the child and involved in their daily care.
C. Parents: Parents are the most reliable source for accurate and up-to-date information about their child’s health, developmental history, and current condition. They are directly involved in the child's daily life and care.
D. Medical record: While the medical record contains important historical data, the most current and relevant information about the toddler’s condition and immediate needs should be obtained from the parents.
Correct Answer is ["A","B","D","E"]
Explanation
A. Placing a pad under the patient's head after guiding them to the floor from a standing position: This helps to protect the head from injury if the patient falls. However, guiding the patient to the floor should only be done if it is safe and possible to do so without causing further injury.
B. Avoiding placing any objects in the mouth when the patient's teeth are clenched: This prevents the risk of choking or damaging the patient's teeth. It is a common safety measure during seizures.
C. Guiding the patient to the bed from the floor during a seizure: This action is not appropriate during the seizure itself as it may cause injury or disrupt the patient's movement. Instead, the patient should remain in a safe position until the seizure ends.
D. Turning the patient to one side, having a slightly forward-tilted head: This helps to prevent aspiration and facilitates easier breathing during and after the seizure.
E. Using supporting pillows for the patient who is on bed: This helps to protect the patient from injury and provides support, ensuring safety during and after the seizure.
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