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 ["A","D"]

Explanation

A. Provide educational material written at an eighth-grade reading level: Educational material should be understandable to the client, and an eighth-grade reading level is typically accessible for most individuals.
B. Turn on the television in the client's room: Turning on the television can be distracting and is not conducive to effective preoperative teaching.
C. Use technical language in the educational session: Technical language can be confusing for clients; plain language should be used to ensure understanding.
D. Start with the most important information: Prioritizing the most critical information ensures that the client understands essential aspects of their procedure, even if they cannot retain all details.

A. Administer medication for high blood pressure B. Reposition the client every 2 hours C. Starting IV antibiotics D. Administering medication for pain

Correct Answer is B

Explanation

A. Administer medication for high blood pressure: This is a dependent intervention as it requires a healthcare provider's order and is part of prescribed treatment.
B. Reposition the client every 2 hours: This is an independent nursing intervention, as it involves routine care that nurses can perform without needing a specific provider's order.
C. Starting IV antibiotics: This is a dependent intervention that requires a healthcare provider’s order and typically involves more specialized procedures.
D. Administering medication for pain: This is also a dependent intervention because it requires a healthcare provider's prescription and direction for administration.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is ["A","D"]

Explanation

The nurse is reviewing interventions written for a client. Which of the following should the nurse consider as being independent?

Correct Answer is B

Explanation

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 preparing a teaching plan for a client who has diabetes mellitus. Which of the following actions should the nurse plan to take first?

38: A nurse in a mental health facility is caring for a client who has antisocial personality disorder and alcohol dependency. The nurse should encourage the client to participate in which of the following groups?

Which of the following is essential when restraints are applied to a client?

A nurse is preparing to transfer a client who has left-sided weakness from a sitting position in bed to a chair. Which of the following actions should the nurse take?

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

The nurse is reviewing interventions written for a client. Which of the following the nurse will consider as being independent?