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 B
Explanation
A. The goal of palliative care is to prolong the life of a client: The primary goal of palliative care is to improve the quality of life by alleviating symptoms and providing support, rather than specifically prolonging life.
B. Palliative care is not restricted to clients who are terminally ill: Palliative care can be provided to any client with a serious illness, regardless of the stage of their condition. It focuses on comfort and quality of life rather than just end-of-life care.
C. Palliative care should be avoided for a client who is receiving a cure: Palliative care is not mutually exclusive with curative treatment. It can be provided alongside curative therapies to manage symptoms and improve the client’s quality of life.
D. Palliative care is limited to clients who are in a health care facility: Palliative care can be provided in various settings, including at home, in outpatient clinics, and in healthcare facilities. It is not restricted to any particular location.
Correct Answer is B
Explanation
A. Irrigate and perform a dressing change for a client who has a pressure injury wound: This task requires specialized knowledge and skill, particularly in wound care management. It involves assessing the wound, choosing appropriate dressings, and monitoring for signs of infection, which are beyond the scope of duties for assistive personnel.
B. Obtain a daily weight on a client who has heart failure: This task is suitable for delegation to an assistive person because it is a routine, non-invasive procedure that does not require clinical judgment or assessment. It helps in monitoring the client's condition, especially in heart failure management.
C. Teach the use of an incentive spirometer to a postoperative client: Teaching involves educating the client on the proper technique and benefits of using the device, which requires nursing judgment and the ability to address questions or concerns. This task should be performed by a nurse.
D. Administer oral PRN pain medication to a client who has arthritis: Administering medications involves evaluating the client’s pain level, assessing potential side effects, and ensuring the correct medication is given, which requires a nurse’s clinical judgment and knowledge.
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