The nurse is collecting data during an initial assessment. The patient tells the nurse, "i have a tremendous headache and my stomach is upset." These findings are called:
symptoms
signs
assessments
Observations
The Correct Answer is A
A. Symptoms – Symptoms are subjective findings reported by the patient, such as headache or nausea, which cannot be measured directly by the nurse.
B. Signs – Signs are objective findings that can be observed or measured, such as a fever or rash.
C. Assessments – An assessment is the process of gathering data but is not a specific term for patient-reported issues.
D. Observations – Observations refer to what the nurse sees or detects rather than what the patient reports.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A"]
Explanation
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+.
Correct Answer is C
Explanation
A. Bruits – Bruits are vascular sounds caused by turbulent blood flow, typically heard over arteries.
B. Crackles – Crackles (rales) are discontinuous, crackling breath sounds caused by fluid in the alveoli, often heard in pneumonia or heart failure.
C. Wheezing – Wheezing is a high-pitched, whistling sound heard during breathing, usually caused by narrowed airways due to asthma, bronchitis, or allergic reactions.
D. Turgor – Turgor refers to skin elasticity and is used to assess hydration status, not lung sounds.
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