A nurse is collecting data from a 70-year-old man who has coronary artery disease (CAD) and hypertension (HTN) Which of the following findings will the nurse report as "signs?" (select all that apply)

A. Peripheral pulses that can be assessed include brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, and posterior tibial. – These are key arterial pulse points used to assess circulation and vascular health.

B. Assess the radial pulse rate by counting the pulsations for 60 seconds. – Counting for a full minute provides the most accurate heart rate measurement, especially if irregularities are present.

C. On a person with good cardiac function and distal perfusion, capillary refill should take less than 6 seconds. – Normal capillary refill time (CRT) is ≤2 seconds. A refill time >2 seconds suggests poor perfusion.

D. The strength of the pulse can be measured using the following scale: 0, 1+, 2+, and 3+. –. The standard pulse grading scale ranges from 0 to 4+.

A. Dizziness, especially when rising from a sitting position – Dizziness is a subjective symptom reported by the patient rather than an objectively observed sign.

B. Blood pressure 145/84 – Blood pressure is an objective measurement and is considered a sign because it can be directly observed and recorded.

C. Unexplained weight gain since his last clinic visit 1 month ago – Weight gain is a measurable and observable change, making it a sign, especially in conditions like heart failure.

D. Exertional dyspnea – Exertional dyspnea (shortness of breath with activity) is a subjective experience reported by the patient, making it a symptom rather than a sign.

E. Has been sleeping on 2 pillows for the past 2 weeks – The need for multiple pillows to relieve breathing difficulty (orthopnea) is a subjective symptom, not an observable sign.

F. 2+ edema in J.M.'s legs – Edema (swelling) is an observable physical finding, making it a sign. It is commonly associated with heart failure and fluid retention.