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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Infection. – Infection refers to the invasion of body tissues by microorganisms, while inflammation is the body’s response to injury or infection.
B. Ecchymosis. – Ecchymosis refers to bruising caused by blood leakage under the skin, not a protective response.
C. Erythema. – Erythema is redness of the skin due to increased blood flow, which is a symptom of inflammation but not the process itself.
D. Inflammation. – Inflammation is the body’s protective response to injury, infection, or irritation. It involves increased blood flow, immune cell activation, and chemical mediators to promote healing.
Correct Answer is B
Explanation
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.
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