A. Apnea- Apnea is the absence of breathing, typically seen in conditions like sleep apnea or respiratory arrest.

B. Orthopnea – Orthopnea refers to difficulty breathing when lying flat, which improves when sitting or standing. It is commonly seen in conditions like heart failure and chronic lung disease.

C. Tachypnea – Tachypnea is an increased respiratory rate, often caused by fever, anxiety, or metabolic acidosis.

D. Dyspnea – Dyspnea is the general term for difficulty breathing, which can occur in various conditions but does not specify the need to sit or stand for relief.

A. A complete physical examination – While a physical examination is part of data collection, the primary goal of a nursing assessment is to guide nursing care rather than conduct a full medical examination.

B. A medical assessment – Medical assessments are conducted by physicians to diagnose diseases, while nursing assessments focus on holistic patient care.

C. Writing nursing orders – Nursing orders are based on the care plan but do not encompass the entire purpose of the assessment.

D. An individualized plan of care – The primary purpose of a nursing assessment is to collect data to create a care plan tailored to the patient's specific needs.

A. Functional disease – A functional disease refers to a condition where symptoms occur without an identifiable structural or biochemical cause, such as irritable bowel syndrome (IBS).

B. Chronic disease – Diabetes mellitus is a lifelong condition requiring ongoing management through diet, medication, and lifestyle modifications.

C. Acute disease – Acute diseases have a sudden onset and short duration, such as influenza or appendicitis, unlike diabetes, which persists over time.

D. Contagious disease – Diabetes is not caused by infectious agents and cannot be transmitted from person to person.

A. Bruits – Bruits are abnormal vascular sounds heard over arteries, often due to turbulence from a narrowed vessel.

B. Tympany – Tympany is a drum-like sound produced during percussion over areas filled with air, such as the stomach.

C. Crackles – Crackles (rales) are discontinuous, bubbling breath sounds often heard on inspiration. They are associated with conditions like pneumonia, heart failure, and pulmonary fibrosis.

D. Thrill – A thrill is a palpable vibration over an artery or heart valve, indicating turbulent blood flow.

A. Diaphoresis – Diaphoresis refers to excessive sweating, which can be caused by fever, infections, hyperthyroidism, or stress.

B. Hypoxia – Hypoxia is a condition where tissues do not receive adequate oxygen, leading to symptoms like confusion and cyanosis.

C. Hemoptysis – Hemoptysis is the coughing up of blood, commonly seen in tuberculosis, lung cancer, or pulmonary embolism.

D. Tachypnea – Tachypnea is rapid breathing, which may occur due to fever, anxiety, or metabolic acidosis but does not involve excessive sweating.

A. Nursing assessment – A nursing assessment is the broader process of gathering patient information, including subjective and objective data, but does not specifically refer to a body system review.

B. Nursing interview – A nursing interview is a method used to gather subjective data from the patient, but it does not systematically review all body systems.

C. Health history – A health history includes past medical conditions, surgeries, and family history but does not systematically assess all body systems.

D. Review of systems – The review of systems (ROS) is a structured approach where the nurse systematically collects data about normal function and any changes in each body system.

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.

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.

A. Bruit – A bruit is an abnormal swishing sound heard over an artery due to turbulent blood flow, often caused by atherosclerosis or narrowing of the vessel.

B. Crackle – Crackles are abnormal lung sounds caused by fluid in the alveoli, not vascular turbulence.

C. Thrill – A thrill is a palpable vibration over a blood vessel or heart valve, indicating turbulent blood flow but is felt rather than heard.

D. Wheeze – A wheeze is a high-pitched respiratory sound caused by narrowed airways, not vascular abnormalities.

A. Opening of the AV valves – The AV (atrioventricular) valves open silently during diastole; they do not create the "lub" sound.

B. Closing of the semilunar valves – The closing of the semilunar valves (aortic and pulmonary) produces the "dupp" sound, not the "lub."

C. Closing of the AV valves – The first heart sound (S1), or "lub," occurs when the mitral and tricuspid (AV) valves close at the beginning of systole.

D. Opening of the semilunar valves – The semilunar valves open silently during ventricular contraction; they do not produce the "lub" sound.