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","D","E","F"]
Explanation
A. The client will teach back information about safe crutch walking on day 1: This goal includes a specific time frame ("on day 1") which makes it a timed component. It establishes when the client is expected to demonstrate understanding, aligning with the SMART criteria for setting time-specific goals.
B. The client will demonstrate safe crutch walking: While this goal describes a desired outcome, it does not include a time frame, so it lacks the timing component needed for SMART criteria.
C. The client will not lean on the crutches to support their body weight: This goal focuses on the behavior change but does not specify when this should be achieved, missing the timed element of SMART goals.
D. The client will ambulate 5 feet in one day: This goal has a specific time frame ("in one day"), indicating when the client should achieve the goal, which is a critical aspect of SMART outcomes.
E. The client will walk 10 feet by day 2: This goal includes a specific time frame ("by day 2"), providing a clear deadline for achieving the goal, which is essential for SMART objectives.
F. The client will walk 20 feet by day 3: This goal includes a specific time frame ("by day 3"), which provides a deadline for reaching the goal, meeting the criteria for SMART goals.
G. The client will explain 4 principles of crutch safety: This goal describes an outcome but does not include a time frame, so it lacks the timed aspect necessary for SMART goals.
H. The client will explain how to keep crutches in safe condition: This goal focuses on an outcome without specifying a deadline, thus missing the timed component required for SMART goal setting.
Correct Answer is C
Explanation
A. Question-and-answer: This strategy involves the nurse asking questions to assess the client's understanding and provide information, but it does not involve the client performing the skill.
B. Role-play: Role-play involves the client acting out scenarios to practice skills, but this is not the method being described where the client is simply asked to perform a skill.
C. Return demonstration: This strategy involves the client performing a skill or procedure after being shown how to do it, allowing the nurse to assess the client's competence in the skill. This is the method being described in the scenario.
D. Discussion: Discussion involves talking through concepts or information but does not include the client actively performing a skill.
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