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 A
Explanation
A. Exudate – Exudate is fluid rich in proteins and cells that escapes from blood vessels due to inflammation or injury.
B. Pus – Pus is a thick, yellowish-white exudate containing dead cells and bacteria, specifically associated with infection.
C. Drainage – Drainage is a general term for any fluid leaving the body, including exudate, blood, or serous fluid.
D. Discharge – Discharge is a broader term referring to any material exiting the body, including normal secretions and infectious material.
Correct Answer is B
Explanation
A. Pruritus. – Pruritus refers to itching, not redness or inflammation.
B. Erythema. – Erythema describes redness of the skin or mucous membranes due to capillary dilation, commonly seen in infections, sunburn, or allergic reactions.
C. Turgor. – Turgor refers to skin elasticity and is used to assess hydration status. It does not indicate redness or inflammation.
D. Exudate. – Exudate refers to fluid drainage from wounds or infections, not skin redness.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
