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 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.

A. 214 B. 212 C. 216 D. 208

Correct Answer is D

Explanation

A. 214: Although this is a negative-pressure room, it is semi-private, which is not ideal for clients with suspected tuberculosis or similar conditions requiring isolation due to airborne transmission.
B. 212: This is a positive-pressure room, which is not suitable for clients with suspected airborne infections, as it could potentially spread the infection to other areas.
C. 216: This is a private, positive-pressure airflow room, which is not appropriate for the client with suspected airborne infection due to potential cross-contamination risks.
D. 208: This is a private, negative-pressure airflow room, which is ideal for clients with suspected airborne infections, such as tuberculosis. Negative-pressure rooms prevent the spread of airborne pathogens to other areas.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is D

Explanation

A nurse is teaching a class about stress. The nurse should include that which of the following is a manifestation of prolonged stress

Which nursing action would be appropriate to protect a patient during a seizure? (Select all that apply)

A nurse is preparing to provide preoperative teaching for a client. Which of the following actions should the nurse plan to take?

A nurse is teaching a newly licensed nurse about orthostatic hypotension. Which of the following information should the nurse include?

A hospice nurse tells another nurse that they are feeling overwhelmed after caring for multiple clients who are dying and reports having difficulty feeling sympathy for their clients. The nurse has manifestations of which of the following conditions?

A nurse is about to perform postmortem care of a client. The family wishes to view the body. Which of the following actions should the nurse take? (Select All that Apply.)

A nurse is reviewing a client's medical record. Which of the following findings should the nurse identify as a fall risk?

A nurse is caring for a client who reports experiencing flashbacks of a traumatic event that occurred a year ago. The nurse should identify that the client is experiencing which of the following stress-related disorders?