ATI RN
ATI Msn De5320 Fundamentals Exam Questions
Extract:
Question 1 of 5
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
Correct Answer: C
Rationale: The correct answer is C because "Guarding and restricted movement" represents the "S" component in the PES format. The S stands for "Signs and Symptoms" in nursing diagnosis. In this case, the patient's guarding of the incisional area and resisting movement are observable signs of pain. The patient's behavior of guarding the area is a physical manifestation that can be observed by the nurse.
A: Acute Pain is the nursing diagnosis itself, not a component of the PES statement.
B: Natural swelling is not mentioned in the scenario and is not related to the patient's behavior of guarding and resisting movement.
D: "Related to incisional trauma" is part of the "P" (Problem) component in the PES format, which identifies the patient's health problem.
Question 2 of 5
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Question 3 of 5
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Question 4 of 5
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Question 5 of 5
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