The nurse is caring for a patient with a painful back injury that occurred 6 months ago. Which nursing diagnosis—using the Problem-Etiology-Symptoms (PES) system—is best?
a. Acute pain related to patient pain rating of 6 as evidenced by muscle spasms and nerve compression
b. Chronic pain related to muscle spasms as evidenced by patient pain rating of 8 and difficulty walking
c. Acute pain related to inability to sit as evidenced by muscle spasms
d. Pain as evidenced by herniated lumbar disk
ANS: B
"Chronic pain related to muscle spasms as evidenced by patient pain rating of 8 and difficulty walking" uses the PES system and uses measurable data as evidence. This best guides the nurse's care and evaluation of the outcome. The other options do not provide appropriate etiologies or measurable evidence.
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