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 C
Explanation
A. Past health history. – Past health history focuses on previous medical conditions, surgeries, and treatments, not current lifestyle habits.
B. Environmental history. – Environmental history pertains to exposure to environmental factors such as occupational hazards or pollutants, not lifestyle habits.
C. Psychosocial history. – Psychosocial history includes information about the patient’s lifestyle, habits (e.g., smoking, alcohol use), social relationships, stress levels, and coping mechanisms.
D. Family history. – Family history focuses on genetic and hereditary diseases present in the patient’s family, not personal habits and lifestyle.
Correct Answer is A
Explanation
A. Assess for level of consciousness and orientation – Level of consciousness (LOC) and orientation are crucial in evaluating neurological status, overall health, and potential signs of deterioration. This assessment provides immediate information about the patient’s cognitive function and responsiveness.
B. Check for pitting edema – Assessing for pitting edema is important but is not the first priority unless the patient has signs of fluid overload or heart failure.
C. Assess the skin – Skin assessment is essential but should be performed after ensuring the patient's neurological stability.
D. Listen to lung sounds – While lung auscultation is an important part of the assessment, it follows after assessing consciousness and orientation.
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.