The nurse is caring for a patient with schizophrenia who is recovering from open abdominal surgery. The nurse observes the patient grimacing and guarding his abdomen. From the information provided, what priority nursing diagnosis will the nurse formulate
1. Disturbed thought processes due to surgery, evidenced by tachycardia and tachypnea.
2. Acute pain due to surgery, evidenced by facial grimacing, tachycardia, and tachypnea.
3. Acute pain caused by surgery, manifested by facial grimacing, tachycardia, and tachypnea.
4. Disturbed thought processes caused by schizophrenia, manifested by tachycardia and tachypnea.
Answer: 2
Explanation: Acute pain due to surgery, evidenced by facial grimacing, tachycardia, and tachypnea is the priority nursing diagnosis for this patient. All nursing diagnoses are formulated the same way: A problem is identified and the words "due to" are used, followed by the causative agent. The words "as evidenced by" are then used, followed by the patient's manifestations or presenting symptoms. While the patient has schizophrenia, the clinical scenario does not indicate that the patient is having disturbed thought processes. The priority nursing diagnosis addresses the patient's basic need of pain relief.
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