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)
Dizziness especially when rising from a sitting position
Blood pressure 145/84
Unexplained weight gain since his last clinic visit 1 month ago
Exertional dyspnea
Has been sleeping on 2 pillows for the past 2 weeks
2+ edema in J.M's legs
Correct Answer : B,C,F
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Auscultation. – Auscultation (listening to body sounds) is important, but it is not the most frequently used skill in an overall assessment.
B. Percussion. – Percussion (tapping on body surfaces to assess underlying structures) is used selectively, not as frequently as inspection.
C. Inspection. – Inspection (visual examination) is the most frequently used assessment technique. Nurses use it to observe skin color, posture, wounds, and general appearance before using other techniques.
D. Palpation. – Palpation (feeling with hands) is essential but follows inspection in the assessment process.
Correct Answer is C
Explanation
A. Causative. – Causative factors directly lead to a disease (e.g., bacteria causing an infection), while risk factors increase the likelihood of developing a disease.
B. Etiological. – Etiology refers to the study of disease causes, but risk factors contribute to disease development rather than being the direct cause.
C. Risk. – Risk factors increase an individual's susceptibility to disease. Examples include smoking (lifestyle), genetic predisposition, and aging.
D. Hazardous. – Hazardous factors refer to dangers or unsafe conditions (e.g., environmental hazards) rather than biological predispositions to disease.
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