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."
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Financial difficulties: Correct. Financial difficulties are a psychological stressor as they impact mental and emotional well-being, contributing to stress.
B. Hypothermia: This is a physiological stressor, as it involves a physical condition affecting the body's health rather than psychological aspects.
C. Burn injury: This is also a physiological stressor resulting from physical harm rather than a psychological impact.
D. Wrist fracture: This is a physical stressor due to injury, not a psychological one, as it affects physical health rather than mental well-being.
Correct Answer is D
Explanation
A. Episodic acute stress: This term is not a recognized diagnosis. Acute stress disorder and posttraumatic stress disorder are the established diagnoses related to trauma and stress.
B. Irritable bowel syndrome (IBS): IBS is a gastrointestinal disorder characterized by abdominal pain and altered bowel habits. It is not related to the flashbacks of traumatic events.
C. Acute stress disorder (ASD): ASD occurs within the first month after exposure to a traumatic event and involves symptoms like intrusive memories and flashbacks. However, since the traumatic event occurred a year ago, this disorder is less likely than PTSD.
D. Posttraumatic stress disorder (PTSD): PTSD is characterized by symptoms such as flashbacks, nightmares, and severe anxiety following exposure to a traumatic event. Given the traumatic event happened a year ago, the client’s symptoms are consistent with PTSD.
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