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

Answer and Explanation

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.

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Correct Answer is B

Explanation

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. prevent distortion of bowel sounds. B. prevent distortion of vascular sounds C. determine any areas of tenderness or pain D. allow the patient to relax and be comfortable

Correct Answer is A

Explanation

A. Prevent distortion of bowel sounds. – Palpation can stimulate peristalsis and alter bowel sounds, leading to inaccurate assessment findings.

B. Prevent distortion of vascular sounds. – While palpation might affect vascular sounds slightly, this is not the primary concern when assessing the abdomen.

C. Determine any areas of tenderness or pain. – While assessing for tenderness is important, auscultation precedes palpation primarily to avoid altering bowel sounds.

D. Allow the patient to relax and be comfortable. – While relaxation is beneficial, the sequence of assessment is based on maintaining accuracy in findings rather than patient comfort.

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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)

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Naxlex Comprehensive Predictor Exams

When the patient asked the nurse how long it would take to "get over" the diabetes, the nurse explained that she will have this disease throughout her life. Diabetes mellitus is considered a/an:

Correct Answer is B

Explanation

The main reason that auscultation precedes palpation of the abdomen is to:

Correct Answer is A

Explanation

An abnormally rapid heart rate above 100 beats per minute is called:

The nurse uses a systematic method for collecting data on all body systems including normal functioning and any noted changes. This system is:

Although the signs and symptoms of both infection and inflammation include erythema, edema, and pain, the major difference is that inflammation:

When the color of the sclera is yellow due to bilirubin that infiltrates all tissues of the body it is called:

Fluid, cells or other substances that have been slowly discharged from body cells or blood vessels, through small pores or breaks in the cell membrane are called:

An abnormally slow heart rate, below 60 beats per minute is called:

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)

During the nursing interview, several histories are taken. The history that involves data concerning habits and lifestyle patterns is called: